Inspection on 05/05/09 for Hooton Chase

This inspection was carried out on 5th May 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hooton Chase 05/10/09

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 07/08/2009.

Key inspection report CARE HOME ADULTS 18-65 Hooton Chase 1 Hooton Road Ellesmere Port Cheshire CH66 1RU Lead Inspector Mr Paul Kenyon Unannounced Inspection 5 and 14th May 2009 09:40 th Hooton Chase DS0000072665.V375186.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. Hooton Chase DS0000072665.V375186.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 Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hooton Chase Address 1 Hooton Road Ellesmere Port Cheshire CH66 1RU 0151 512 2568 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) Mr Mohamad Jeelany Meeajun Gaynor Patten (Acting Manager) Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Hooton Chase DS0000072665.V375186.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 people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability- Code LD The maximum number of people who can be accommodated is: 12 Date of last inspection Not Applicable Brief Description of the Service: Hooton Chase is situated in semi rural area on the border between Cheshire and Wirral near to Ellesmere Port. It comprises of a detached two storey property which is located within its own grounds. The service is registered for 12 adults who have a learning disability. The service was registered in December 2008 and is owned by Mr Mohamad Jeelany Meeajun. The Manager Gaynor Patten is currently in an Acting position yet has applied to the Care Quality Commission for registration to become Registered Manager. Hooton Chase DS0000072665.V375186.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 0 stars. This means the people who use this service experience poor quality outcomes. This was our first visit to Hooton Chase since we first registered the service in 2008. The staff were not aware that the visit to take place. During the visit we interviewed staff, looked at records relating to the support provided, interviewed the people who live at Hooton Chase and toured the premises. Any comments made by staff and individuals using the service are included in this report. In addition to this we received surveys from staff members and other people who live at Hooton Chase who were not present during our visit. What the service does well: The service enables the people who use the service to make decisions about their lives. People who wish to carry on pursuing education are enabled to do so. People are enabled to access the community when they wish. The rights of people are promoted by the service. Meals provided by the service are in line with the preferences of individuals. The service provides support in line with the preferences of individuals. The health needs of individuals are promoted by the service. Individuals can be confident that the service will investigate any complaints they have thoroughly. Individuals are protected by the policies, procedures and training provided by the service in relation to safeguarding. Individuals are supported by well trained staff. ‘I have settled in’ ‘My room is alright it is upstairs and I can get to it-it is being decorated and I chosen the colour and the bedding’ ‘I go out-shopping and round and about’ ‘I tell the staff what I want’ ‘If I was not happy I would talk to staff’ Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 6 ‘The food is nice’ ‘Staff are alright they look after me and they are nice’ ‘I feel safe-I get involved in cleaning and hoovering-I have my own bank account’ ‘I always get the care I need’ ‘Staff are available’ ‘Staff listen and act on what I say’ ‘I always get the medical care I need’ ‘There are activities’ ‘I like the meals’ ‘I know how to complain’ ‘The home is fresh and clean’ ‘I am happy with everything’ ‘The best thing about working here is the reaction you get from service usersnothing needs improving’ ‘I have been supported a lot and learned a lot’ ‘The service is good at supporting staff and clients, ensures people’s needs are met. I get regular supervision. The manager ensures that regular training is done-she is approachable-the staff team work well together’ ‘Hooton Chase meets all the needs of people physical, mental or emotional. The staff are important. There is a support network for all individuals in their care and to the families who we provide respite for. We could do with better staff facilities.’ ‘We do everything well-we seem to meet everyone’s needs who have resided here whether permanent on respite. I can’t find any faults-everything is fine’ What has improved since the last inspection? What they could do better: The service must obtain assessments relating to all people who come to use the service so that their needs can be identified and met Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 7 The service must devise care plans for all individuals so that their needs can be identified and met The service must devise individual risk assessments so that the health and safety of the people who use the service can be promoted All medication records should include records of when medication has been received and signatures to indicate when medication has not been administered so that the health and safety of the people who use the service can be promoted through the safe management of medication The electric wall socket in the lounge must be secured to ensure the health and safety of all who use the premises Natural ventilation must be available in Room 9 by ensuring that the window opens freely. The freezer in the laundry must be removed to ensure that food safety is promoted A minimum of two references must be available on personnel files to ensure that the people who use the service are protected by the recruitment process Criminal record checks and POVA First checks must be available on staff files to ensure that the people who use the service are protected by the recruitment process Unannounced visits must be undertaken by the provider on a monthly basis so that a report on the standard and quality of care can be produced. This would ensure that the quality of care meets the needs of the people who use the service. Portable appliances must be tested to ensure that their use promotes the health and safety of the people who use the service and staff. There must be periodic checks to fire detection systems and undertaking of fire evacuation drills to ensure the health and safety of the people who use the service and staff. General assessments relating to the risks faced by the people who use the service and staff through the use of the premises on a daily basis must be produced. A number of good practice recommendations are also raised in this report. Hooton Chase DS0000072665.V375186.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. Hooton Chase DS0000072665.V375186.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 Hooton Chase DS0000072665.V375186.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): 2 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. The needs of those who come to live at Hooton Grange are not consistently assessed before they come to use the service and as a result their needs are not fully met. EVIDENCE: We looked at information for two individuals who were currently using the service at Hooton Chase. The information suggested that two people were using Hooton Chase for respite. In one case, the Local Authority who are responsible for paying for the support this person receives had provided the service with a summary of the person’s needs. With another person, no information had been received at all. Another person who had used the service in the past for respite was in hospital while their future accommodation was being decided. Again, no information had been received about this person’s needs. On the first day of our visit, we noted that another person was coming to live at Hooton Chase later that week. The service had assessed this person’s needs and provided a summary of their needs with daily living. Hooton Chase DS0000072665.V375186.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 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. Those who live at Hooton Chase do not have their needs met given that the service has not devised care plans for anyone. Individuals are provided with the opportunity to make decisions about their lives and have their financial interests safeguarded. The health and safety of individuals is not promoted given that the service has not assessed the risks faced by individuals in their daily lives. EVIDENCE: We looked at information relating to three people who were either using the service or used the service recently. No care plans were available for these individuals. Daily records were available for two people. Records provided a detailed account of each person’s progress and daily lives. The service must devise care plans so that the needs of people can be identified and met. Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 12 In respect of decision making, one person was reported as being able to communicate verbally and would be able to make decisions based on this. Another person is reported as having no verbal communication although a chart including symbols was available for the person to use to indicate what they wanted. The symbols related to likes or dislikes, activities, meals, and emotions. We talked to one person. This person was able to communicate verbally. They were able to confirm that they had been given the opportunity to make decisions ranging from the colour scheme in their bedroom to meals and what they wished to do day to day in respect of education. At present the service has no involvement with the finances of individuals. One person confirmed that they have their own bank account. One person receives assistance from an advocate although this has been for when the person lives at home rather than Hooton Chase. No risk assessments are available for any one using the service. The service must devise these in order to ensure the heath and safety of individuals. Hooton Chase DS0000072665.V375186.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, 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. The people who use the service are able to access education if they wish and can access the local community. They are able to maintain contact with their families and generally have their rights respected. The nutritional needs of people are taken into account although the lack of assessments and care plans means that there is an incomplete picture of their dietary needs. EVIDENCE: Two individuals using the service at Hooton Chase currently attend local educational facilities. One person who has just come to live at Hooton Chase has declined to attend a day centre facility and has outlined her reasons to the staff team. These have been respected and alternative opportunities are being looked at. Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 14 For individuals who use the service for respite, when they are not attending education placements, they are able to pursue some activities in the local community while staying at Hooton Chase. They use public transport or taxis. The service does not have its own transport at present. Local transport links are available with a railway station and bus routes close by. Activities are limited at present. It is recommended that these are extended. One person who has come to live at Hooton Chase confirmed she goes out shopping and is able to get ‘out and about’. Given that the service mainly offers respite to individuals, the level of family contact is not applicable at present. There are no locks on any bedroom doors at present and as a result no keys have been issued to individuals in order for them to secure their rooms. It is recommended that this is pursued by the service and linked to risk assessments when they are completed. We observed the way staff interact with the people who use the service. Staff spoke with individuals in a positive manner through observation. Staff asked people what they wanted to do and explained to them what they needed to do at any time e.g. going out to the shops etc. Staff interact with individuals and not just between themselves. Discussions with one person confirmed that they are involved in domestic tasks such as sorting out their laundry, cleaning and hoovering. They stated that they were not involved in cooking at this time but tended to assist in washing up and setting tables for meals. Evidence was available that other people are involved in household tasks. No one has any special dietary needs at present although the absence of any initial assessments in place means that this cannot be fully confirmed when people come to use the service to confirm this. We talked to one person about meals. This person is on a healthy eating plan and seems to enjoy her meals. A menu is available but this is flexible given that staff were observed talking to people about what they wanted to eat that evening. A record of food provided is included within daily records. One person confirmed that they were involved in all tasks in the kitchen with the exception of preparing meals and will go to local shops to shop for food. A dining room is available as well as a kitchen. This is domestic in scale. Refrigerators and freezers are available and are well stocked. Two people confirmed that they enjoyed the food provided. Hooton Chase DS0000072665.V375186.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 and 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. The absence of care plans for some individuals means that the level of support they require cannot be determined and their needs are not met. The health needs of individuals once identified are met. The management of medication does not promote the health and safety of individuals using the service. EVIDENCE: The absence of care plans means that the level of support needed by these some individuals cannot be determined. Two people were able to confirm that they had their own clothes and could choose what they wanted to wear. They are able to maintain their own appearance. There is no need for mobility aids given that no one needs assistance with mobility. Two people confirmed that they were able to move around the building unaided and access their bedrooms on the first floor of the building. One person currently receives support from a Community Psychiatric Nurse. Another person receives support from their Doctor, an incontinence nurse and a speech therapist. One person considered: ‘Staff are alright they look after me and they are nice’. Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 16 The lack of assessment information and care plans means that it is difficult to identify any ongoing medical issues. Information retained by the service suggests that details of Doctors were available for one person. Another person contains information of contact with their Doctor, incontinence nurse and speech therapist. One person’s health needs have been identified in the assessment completed by the service. The lack of assessments for one person who used the service means that while district nurses attended this person and he was admitted to hospital, no information had been made available in respect of a health condition. No one has needed to attend health appointments of late while at Hooton Chase. Medication is stored in locked room which in turn contains separate secure facilities for each person’s medication. No one takes medication at present and there is no history of anyone else taking their own medication. Past medication records are retained and were examined. There was no evidence that any received medication had been recorded. There was also evidence that when people were in hospital, no records were made on their medication record to reflect this. These are raised as requirements in this report to ensure that the service manages medication to promote the well being of individuals. Staff interviews confirmed that they have received medication awareness training. This was evidenced through interviews and by the presence of training certificates. Hooton Chase DS0000072665.V375186.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 and 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. The people who use the service are able to influence the care they receive through the presence of a complaints procedure. The people who live at Hooton Chase are protected from abuse by the policies and procedures in place as well as the training staff receive. EVIDENCE: We talked to two people who use the service. Both confirmed that they would speak with staff if they were concerned about the support they received. Staff surveys were returned to us and these suggested that staff were aware of what to do if they received a complaint. No complaints have been received about the service since it was first registered. A complaints procedure is available for those who live there and was on display in the building. A complaints record is available. The service has obtained a copy of the local authority procedure on referring allegations of abuse. Staff confirmed through interviews and surveys that they have received safeguarding training. They also confirmed that they are aware of the whistle blowing procedure and our role. No allegations of abuse have been raised in respect of Hooton Chase. Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 18 Information in respect of one person who was coming to live at Hooton Chase noted that this person had the potential to display some aggressive behaviour. A management plan has been devised by a health professional in order for staff to manage this. Individuals who we spoke with confirmed that they felt safe at Hooton Chase. Hooton Chase DS0000072665.V375186.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 and 30 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. The people who live at Hooton Chase live in an environment which needs some attention to ensure that it is well maintained. While the environment is generally hygienic, work in needed in relation to preventing contamination of foodstuffs from soiled laundry. EVIDENCE: We toured the premises. The building is set in own grounds within a semi rural area on border between Cheshire and Wirral. It is a two-storey building and contains many original period features. The service is close to public transport links and cannot be distinguished as a care service given that it blends in with the local community. Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 20 Our tour of the building noted that there was sufficient communal space for individuals. There are two lounges, a dining room and a seating area on the first floor landing. While the building is generally decorated to a good standard, it was noted that corridor areas and lounges did appear to be bare and did not include items such as pictures that would create a more home like environment. It is recommended that this is done. Some repairs were identified as needed as a result of our tour around the building. In one lounge, an electrical socket was loose. In one bedroom, a window could not be opened and as result there was no natural ventilation in the room. One person showed us their bedroom. They stated that they were happy with it and has all their personal possessions available to. Another person confirmed they were happy with their room and that they had been given the opportunity to choose the colour scheme in the room to their own tastes There is no passenger lift in the building given that the service at present only provides support for those who are fully mobile. Individuals confirmed that they were able to access their rooms on the first floor independently and this was noted during our visit. The building is free of offensive odours and was clean and tidy during our visit. A laundry is available and this contains industrial washing and drying appliances. A chest freezer storing food is located in the laundry. It is required that this is removed so that food safety can be promoted. Interviews with individuals who use the service confirmed that they are involved in the cleaning of their rooms. Hooton Chase DS0000072665.V375186.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): 34 and 35 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. The recruitment process does not fully protect the people who live at Hooton Chase but the training staff receive meets their needs. EVIDENCE: We looked at three personnel files. The information needed to check the suitability of people to work at Hooton House was present in most files but it was found that some police checks were not available on three files, references were absent on one file and no check against the protection of vulnerable adults register had been done for three people. This is raised as requirement in this report so that people living at Hooton Chase are protected by the recruitment procedure. We interviewed a member of staff about training they had received. The person confirmed that they had commenced a National Vocational Qualification at Level 2 and had received training in fire safety, manual handling, principles of care, food hygiene, written communication, abuse training and first aid. The Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 22 staff member has also received medication awareness training. We received staff surveys which commented: ‘The manager ensures that regular training is done’ ‘I have received training relevant to my role, it helps me understand the needs of people and it keeps me up to date with new ways of working’ Training received by staff was confirmed by training records. Hooton Chase DS0000072665.V375186.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 and 42 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 service benefits from having an Acting Manager with the experience and qualifications to do the job although this will be subject to a satisfactory application being received from us. The service does not take the views of those who use the service into account and does not examine the quality of its own practice. The health and safety of those who use the service is not promoted. EVIDENCE: The person who was registered as manager when Hooton Chase was first registered has now left the service. There is a manager who is acting at present. This person has applied to us to become the registered manager. This Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 24 person has had experience of supporting individuals with a learning disability and mental health for the past decade within supported living. She has a National Vocational Qualification at Level 4. The service also has a Deputy Manager in place. We looked at the way the service assesses the quality of its own service. A form providing the opportunity for individuals and their families to comment on the support provided is available but has not yet been completed. It is recommended that this is provided to people so that comments can be made. There was evidence that staff receive supervision sessions with the Acting Manager so that the way they support people can be assessed. We were able to tour all areas of the building and to talk with the people who use the service and staff in private if needed. We were also able to examine all records relating to the support people receive. The provider does not conduct a formal inspection of the service to assess the quality of support provided. It is required that this is done so that people using the service can be confident that the support they get meets their needs. We looked at the way the service promotes the health and safety of people living there. Interviews with staff and the examination of records confirmed that staff have received regular health and safety training. There was no evidence that the service checks to see if fire detection systems are working and have not conducted a recent fire evacuation drill. The service has not assessed any risks that may be faced by both individuals and staff through the daily use of the premises. Although water temperature restrictor valves are in place, there was no evidence that the service checks these periodically to ensure that water temperatures are maintained at a safe level. It is recommended that this is done. While records of accidents are maintained, there was no information on what to do if more serious injuries are sustained. This is known as RIDDOR and information on this should be obtained by the service as a recommendation. There was no evidence that the service checks the health and safety issues in the building through an audit of the premises. It is recommended that this is done given the matters raised in our tour of the building. The security of the building is maintained with the front door being the only means of access to visitors. No portable electrical appliances have been tested in the building to ensure the safety for all in their use. Gas and electrical certificates would have been viewed by our registration team during initial registration of the building in December 2008. The service has ensured that the certificate of registration and insurance certificates are on display. Hooton Chase DS0000072665.V375186.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 X 2 1 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 N/A 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 1 X Version 5.2 Page 26 Hooton Chase DS0000072665.V375186.R01.S.doc 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 YA2 Regulation 14 Requirement The service must obtain assessments relating to all people who come to use the service so that their needs can be identified and met The service must devise care plans for all individuals so that their needs can be identified and met The service must devise individual risk assessments so that the health and safety of the people who use the service can be promoted All medication records should include records of when medication has been received and signatures to indicate when medication has not been administered so that the health and safety of the people who use the service can be promoted through the safe management of medication The electric wall socket in the lounge must be secured to ensure the health and safety of all who use the premises Natural ventilation must be available in Room 9 by ensuring DS0000072665.V375186.R01.S.doc Timescale for action 30/06/09 2 YA7 15 30/06/09 3 YA9 13 30/06/09 4 YA20 13 01/06/09 5 YA24 23 01/06/09 6 YA24 23 01/06/09 Hooton Chase Version 5.2 Page 27 that the window opens freely. 7 8 YA30 YA34 13 19 The freezer in the laundry must be removed to ensure that food safety is promoted A minimum of two reference must be available on personnel files to ensure that the people who use the service are protected by the recruitment process Criminal record checks and POVA First checks must be available on staff files to ensure that the people who use the service are protected by the recruitment process Unannounced visits must be undertaken by the provider on a monthly basis so that a report on the standard and quality of care can be produced. This would ensure that the quality of care meets the needs of the people who use the service. Portable appliances must be tested to ensure that their use promotes the health and safety of the people who use the service and staff. There must be periodic checks to fire detection systems and undertaking of fire evacuation drills to ensure the health and safety of the people who use the service and staff. General assessments relating to the risks faced by the people who use the service and staff through the use of the premises on a daily basis must be produced. 01/07/09 30/06/09 9 YA34 19 30/06/09 10 YA39 26 30/06/09 11 YA42 23 30/06/09 12 YA42 23 30/06/09 13 YA42 13 30/06/09 Hooton Chase DS0000072665.V375186.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 2 3 4 Refer to Standard YA13 YA16 YA24 YA39 Good Practice Recommendations Activities in the local community should be extended to ensure that the people who use the service are provided with as much community contact as possible. The people who use the service should be offered the opportunity to have keys for their bedrooms in order to promote their privacy. Pictures and ornaments should be introduced into communal and corridor areas to ensure that the environment is more home like in appearance The opportunity should be provided to the people who use the service to comment on the quality of support they are provided with so that they are able to influence the running of the service. A health and safety audit of the building should be undertaken at least monthly to ensure that the premises promote the health and safety of all Water temperatures should be monitored periodically to ensure that the health and safety of all is promoted. 5 6 YA42 YA42 Hooton Chase DS0000072665.V375186.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission Unit 1 Tustin Court Port Way Preston PR2 2YQ 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. 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