Inspection on 21/04/09 for Island Place

This inspection was carried out on 21st April 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Island Place 15/10/08

Island Place 21/05/08

Island Place 24/04/07

Island Place 05/06/06

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Key inspection report CARE HOME ADULTS 18-65 Island Place Gooding Avenue Braunstone Leicestershire LE3 1JS Lead Inspector Fiona Stephenson Unannounced Inspection 21st April 2009 08:40 Island Place DS0000066589.V375065.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. Island Place DS0000066589.V375065.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 Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Island Place Address Gooding Avenue Braunstone Leicestershire LE3 1JS 0116 2855518 0116 2855518 islandplace@prime-life.co.uk info@prime-life.co.ukwww.prime-life.co.uk Prime Life 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) Jason Reece-Sumner Care Home 36 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (36) of places Island Place DS0000066589.V375065.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: 2. Mental Disorder, excluding learning disability or dementia – Code MD The maximum number of service users who can be accommodated is 36. 15th October 2008 Date of last inspection Brief Description of the Service: Island Place is registered for up to 36 people who have mental ill health, to live in one of ten apartments in the home. Island Place is part of the Prime Life Group. Car parking is available to the front of the home and it is a ten-minute bus journey to the town centre and the nearby shopping centre, Fosse Park. The living area is located over three floors, accessed through the main reception and entrance to the home. The office, staff room, the large communal lounge and kitchen are located on the ground floor. The upper floors are accessible via the stairs or the passenger lift. Each flat accommodates either three or four people, who have their own bedroom and share a communal lounge, kitchen and dining area and two shower/ toilet facilities. During our inspection visit we were told that fees charged in the home have not changed since the last inspection. Fees begin at £309.00 and increase where someone has been assessed as needing greater levels of care. Additional charges are made for one to one care. There are also additional costs payable for things such as transport, activities and personal items. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use this service experience good quality outcomes. This key inspection included a visit to the service. We (the CQC) visited the home on Tuesday 21st April 2009. The registered manager, Jason ReeceSumner, and staff in the home helped us during the visit. The visit started at 8.40am and finished at 5.50pm. The visit included a check of the service’s medication systems by one of our pharmacy inspectors. As part of our inspection, we sent out ‘Have your Say’ surveys to people who live at Island Place, staff who work there, and to other health and social care professionals who work with people who live at Island Place. We received five back from people who live at the home, eight from staff, and three from health and social care professionals. The five responses we received from people who live at Island Place, were mostly positive. All knew how to make a complaint and felt they could confide in staff. All felt that staff treated them well, and most said that staff listened and acted on what they said. One person said ‘when they want to listen they will talk. I feel I can only speak to certain people’, another said staff are ‘courteous and polite and solve my problems to the best of their abilities’. The eight staff responses were very positive about the service they felt is being provided to people who live at Island Place. They felt that their health and social care needs were being well provided for, and they were receiving good training and support to enable them to work effectively with people who have mental health problems. A number of staff respondents said they would like the service to have its own transport to give more flexibility in the provision of activities for people living in Island Place. The three professionals, who responded, said that staff respect the dignity of service users. Two of the three respondents said that they had seen improvements in the service over the last few months. One said ‘my first impressions of Island place were quite negative (March 2008). The unit appeared to be ineffectively managed, quite chaotic…the new unit manager has since that time worked extremely hard to improve the environment and to train staff who now take a much more active and professional role in working with residents’. Another said ‘I think that the home manages very ‘difficult people,’ i.e. people that have a wide range of mental ill-health, coupled with other social/personal needs very well’. A third professional respondent said ‘staff do contact for advice however they do not appear to take on the advice in the long term and repeatedly report the same issues’. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 6 The main method of inspection we used was ‘case tracking’. This means looking at the care given to people in different ways. We did this by: - talking to people who live at Island Place - talking to staff and the manager - watching how people are given support - looking at written records. We also looked at the AQAA (Annual Quality Assurance Assessment). This is a document the provider (owner) completes, and is their own assessment of how well they feel the service is providing care and support to people who use it. We spoke at length to three people who live at Island Place. People told us that they felt well supported by staff and by the manager of the home. We spoke with five staff during our visit. Staff told us about changes that had happened in the home since the last inspection and about the training they have received. They told us they felt more skilled in being able to provide good care for people with mental health issues. What the service does well: Staff have a good understanding of the care needs of people living at Island Place, and treat people living at the home with sensitivity and respect. People living at Island Place feel able to talk to staff or management about how they feel, and what they want. Staff work well with health and social care professionals who are involved in the care of people who live at Island Place, in informing them of changes of the person’s mental or physical health. People living in Island Place are helped and encouraged to maintain relationships with their family and friends. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? Care plans now clearly show the care needs of people living at Island Place. They are now regularly reviewed, and staff can clearly see the changing care and support needs of people who live at the home. The involvement of health and social care professionals is now clearly documented, as is the advice they give to staff. This advice is fedback into the care planning process. There are now good procedures in place to make sure that medicines are given correctly, and records accurately show what medicines have been given, at what time, and why. Staff have received further training and support in understanding the needs of people who have mental health issues. Staff now feel more knowledgeable and confident in supporting people with mental health problems. Staff have also had training to ensure they ‘safeguard’ the adults in their care. Staff have made links with the local community groups and resources, and people living at Island Place are now having more involvement with activities and resources available in the community. Areas of the home have been redecorated and new flooring has been put down in the hallways of most of the flats. All people moving to Island Place have had their needs properly assessed prior to moving into the home to ensure that the service can meet their needs. The service now ensures it has received all the information it should prior to employing a person, to support the safety of people living at Island Place. Management and staff are working well together to improve the service and the outcomes for people who live at Island Place. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 8 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. Island Place DS0000066589.V375065.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 Island Place DS0000066589.V375065.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): 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. EVIDENCE: We looked at the information given to a person who has been newly admitted to Island Place. We saw that this person received written information about the service prior to moving into the home. We also saw that they had visited the home and had a ‘needs assessment’ undertaken prior to moving in. The ‘needs assessment’ had then been used to develop a Care Plan. The person was given the ‘Terms and conditions of residency’ and they were introduced to their key worker at the beginning of their stay. We looked at the Statement of Purpose. This is a legal document which tells people what service they should expect. We saw that the company had given sufficient information to meet its legal requirements, but that the document did not go into detail about how it will meet the wide ranging needs of people who live at the home. Island Place DS0000066589.V375065.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): 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. EVIDENCE: We looked at care plans and risk assessments (these tell us about whether there are any areas of concerns relating to the individual and how staff can keep them safe whilst encouraging them to maintain independence) for people whose care were tracking. At our last inspection we saw that management had just started to improve care plans which we felt had been poorly managed, we also saw that risk assessments had not always been undertaken leaving people living at the home at risk. This time we saw that the manager and his team had done a lot of work to improve care plans. All of the people we case tracked had good care plans in place that clearly showed what their care needs were and how they Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 12 should be supported by staff. We saw that there had been regular reviews of care plans, and linked to the care plans were well-documented risk assessments. We were told that there were still some care plans and risk assessment which needed up-dating and improving, but management expected all care plans and risk assessments to be improved in the next two months. The people we spoke with who live at Island Place and those who completed the ‘Have your Say’ questionnaire said that they were on the whole, able to make decisions about their lives. We were also informed that people who live in the home are consulted on the way the Island Place is managed. There are now regular meetings with people who live there. We were also told by people we spoke with that they feel able to talk to staff and management if they aren’t happy with aspects of the home, and they are listened to, and if possible, their requests acted upon Island Place DS0000066589.V375065.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: 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. EVIDENCE: During the last two inspections there have been concerns raised about the lack of opportunities for people living at the home to engage in activities both within Island Place, and in the wider community. These concerns had begun to be addressed at the last inspection. This time we saw there had been big improvements in the opportunities that had either been created for people, or were in the process of being created. Staff support people living at Island Place to make use of the local facilities such as Braunstone Leisure Centre and the Brite Centre. People who live at Island Place are supported in using the local park, and staff are looking into supporting residents who enjoy fishing to get a permit to fish at the park. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 14 There are more activities taking place within the home, and people living at Island Place have been to visit other Prime Life homes for lunches. There have been outings to the Tropical Bird Park and Foxton Locks. We were told by staff that the service does not have its own transport, and they have to rely on pre-arranged times with the company mini-bus to arrange trips. We were told that it would be more beneficial for the service to have its own transport as staff would then have more flexibility arranging trips at times which suit the mental health needs of people living at the home. We looked at the information in care files, and spoke with people who live at Island Place, and were told that people, who wish to, maintain family links and friendships inside and outside the home. We saw that staff had supported one person in organising a trip to America to visit their parents. Another told us that they visit their Dad often, and can go out and visit their friends when they want. One person we spoke with felt that they couldn’t invite people back to their flat because others left it untidy, and smoked in areas that they shouldn’t. We watched how staff worked with people who live at Island Place. We saw that staff had good relationships with people who live at the home, and we saw them treating people who live at the home, with respect. When we visited, we were told there were 26 people currently living at Island Place. We were told that although they try to promote independence for people living at the home, 18 people have their meals prepared and cooked for by staff. We were informed that people living at Island Place now have a more healthy diet, and the service is having more fresh fruit and vegetables delivered. We were told that the main meal of the day is provided at lunchtime, and there is usually a sandwich or buffet style tea in the evening. On the day we visited, staff cooked jacket potatoes with tuna mayonnaise, cheese and beans for lunch; and provided a sandwich tea for the evening. Most people living at the home have a breakfast of toast and cereal, with tea, coffee and/or fruit juice. We saw the menu for the two week period prior to our visit. Staff were cooking roast dinners at the week-end, and during the week, they provided cooked dinners such as Shepherds Pie, Lancashire hotpot, burgers, faggots, and chicken curry. All dinners had vegetable accompaniments. We saw that the tea time meal is served on paper plates. We were told that this is because the teas are usually sandwiches or a cold buffet. We were told that staff use paper plates when not giving hot meals, because it reduces the time in the kitchen, washing up the plates and gives them more time to be with the people who live at the home. The service does not have a dishwasher. Island Place DS0000066589.V375065.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): 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. EVIDENCE: We saw that people who live at Island Place are receiving personal support in the way they prefer and require, although staff do not always have time to provide as much emotional and social support as they would like to. Better care planning and assessment processes have improved the understanding staff have of the needs of each person living at Island Place. Each person living at Island Place has a key worker to support them in ensuring their dayto-day needs are met. We found that the outcomes of visits by doctors, nurses and other health and social care professionals were fully recorded in care plans, and information on how peoples’ physical health needs should be met was also given in the care plan. The recording has vastly improved since the last inspection. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 16 At the last inspection we were not satisfied with the way medication was being managed. This time we saw big improvements in the management and administration of medicines. We watched medicines being given out in the morning and at lunchtime, and saw that national guidance on administering medicines was followed. We spoke with one person who was prescribed a medicine that should be taken on an empty stomach and they told us that they took the medicine half to one hour before breakfast. Another person said that they always received their morning medicine on time. We saw that the administration records on medicine charts were accurately completed. We saw that on one chart, the time of day a dose needed to be given had been changed but the person making the change had not signed the chart, and that details of medicines written by hand on to a medicine chart had not been checked by a second staff member. We compared the quantity of some medicines in the home with the medication records and found that the amounts in stock matched the records, (indicating that medicines were given as prescribed by the doctor). We saw that the reference book on medicines was the 2007 edition, and not up to date. We found that staff checked on the well being of people looking after their own medicines each day, although this was not happening with one person. This person’s medication was labelled ‘use as directed’ but there was no assessment of their ability to take the medication correctly in their care plan. We saw that the cupboard used to store controlled drugs met legal requirements. We found that the medicines requiring cold storage were kept in the kitchen fridge as there was no separate medicine refrigerator. The manager told us he was unaware they needed to be stored in a separate fridge. Island Place DS0000066589.V375065.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): 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. EVIDENCE: Staff told us of the training they have received to ‘Safeguard Adults’. Staff responded well to questions about how to keep adults safe, and what they would do if they had concerns that a person living at Island Place was being abused. During our inspection we saw that staff were dealing sensitively and well with a person living at Island Place whose mental health was deteriorating. They had ensured the health and social care professionals who were involved with this person’s care were aware of their concerns and a meeting had been set up to support the person. People living at Island Place were observed to have their views listened to and where possible, acted upon. There have been no formal complaints made about the service since the last inspection. The CQC has also not received any complaints about the service since the last inspection. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 18 Since the last inspection, we have received 14 notifications from Island Place about incidents that have happened to individuals in the home. We were satisfied that these incidents were managed appropriately and that the relevant health and social care professionals were contacted when necessary. Island Place DS0000066589.V375065.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): 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. EVIDENCE: Island Place is a large building which contains within it, 10 flats. Each flat has its own kitchen/diner, living room, two shower rooms and individual bedrooms. There is also a communal lounge on the ground floor and large kitchen on the ground floor. We found the ground floor kitchen and communal lounge to be clean and tidy. The cleanliness in the individual flats was variable. We saw that staff had identified cleanliness as an issue in one of the staff meetings. We found ovens out of order in two of the flats. We were told that parts were on order to fix them. We also found that when the toilet flushed in a couple of the flats, a loud noise continued after the flush stopped, and this continued for Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 20 some time. We were told by one of the people who live at Island Place that this was not unusual. We saw that in the hallways of most of the flats, badly worn and stained carpeting had been replaced with laminate flooring, and this had improved the appearance of the flats. We also saw that some parts of the home had been improved as a result of re-decorated and re-furbishment. At the last inspection we saw evidence to suggest that people are not using the designated smoking areas only, to smoke in the home. Again, during this visit we found evidence in many parts of the home that people are continuing to smoke in non designated areas. We did not see any smoking happening in non-designated areas during this visit; however we did see cigarette butts, and ash left on carpets in non-designated areas. We saw by looking at staff team minutes that staff are aware of the problem and have been looking at ways to ensure that smokers at the home smoke in the designated areas only. Island Place DS0000066589.V375065.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): 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. EVIDENCE: We looked at the staffing at Island Place. At the time of our visit, there were 26 people living at the home with complex mental health needs. They live in a large building, separated into 10 flats, and these flats are on three floors. During 8.00am to 8.00pm there are four carers, and one senior carer on duty. The manager works 9.00am – 5.00pm. In addition, there is one member of staff who is funded to work on a one-to-one basis with a service user, two days a week, and another member of staff who is funded to work on a one to one basis with another service user, Monday to Friday 9.00am to 1.00pm. Staff not only support the physical, emotional and social care needs of people who live at Island Place, but also undertake the cooking and cleaning for the majority of the people who live there. We were told by staff that they are currently cooking for 18 of the 26 people who live at Island Place. They prepare and cook the main meal at lunchtime, and also prepare and cook the Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 22 tea-time meal. Staff told us that preparing and cooking the main meal can take two hours of their time, and then they have to clear up after the meal which can take another hour. During the visit, we went into the kitchen and saw three staff preparing food for tea. Again this reduced the time staff spent with people living at Island Place in supporting them with their other needs. We saw by looking at staff records and by speaking to staff, that they have received training in mental health, and this has been followed up by senior management in the company, by regular meetings with staff to support and grow their understanding of working with people with complex mental health needs. The staff we spoke to confirmed that the training had been useful in understanding how to work with people living at Island Place. Staff also told us that they were in the process of National Vocational Qualifications in care. We saw that staff working at Island Place had good relationships with people who live there. People living there were observed as being comfortable in saying what they wanted to both staff and management. We observed good practice in relation to a challenging situation which developed on the day of our visit. We also observed staff working well with each other. We checked the recruitment records of two people who have recently started working at Island Place. We were satisfied that the recruitment practice had kept people living at Island Place safe. Island Place DS0000066589.V375065.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): 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. EVIDENCE: On looking at the records, talking to people who live at Island Pace, talking to staff, and looking at information that we at the CQC have received, we are satisfied that management have worked hard to address many of the concerns raised during our previous visits. We were told by both staff and people who live at Island Place that they have confidence in the manager and how he is running the home. We saw that the manager is working well with senior members of staff, and is delegating some responsibilities to them to further improve the running of the home. Staff told Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 24 us that they feel supported by the manager, and receive good supervision in their work. We looked at health and safety records e.g. accident and incident records, and staff induction. We also observed staff undertaking tasks during the visit, and saw that they complied with health and safety legislation e.g. food preparation, laundry. The service is trying to comply with the legislation regarding designated smoking areas, however not all people living at the home are supporting this. Island Place DS0000066589.V375065.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 2 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 2 x 3 x 3 x x 2 x Version 5.2 Page 26 Island Place DS0000066589.V375065.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. YA20 Standard Regulation 13 Requirement Medicines requiring cold storage should be kept in a locked fridge used solely for storing medicines. The temperature of the fridge should be monitored by a maximum/minimum thermometer. People who self-medicate must be provided with full, written instructions on how to take their medicines. A risk assessment must be produced for all service users who self administer their medication. Timescale for action 29/05/09 2. YA20 13 29/05/09 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 Refer to Standard YA1 YA20 Good Practice Recommendations The statement of purpose should give more detail about how the service will support the range of needs in the home – from the less dependent, to the more dependent. An up to date copy of the British National Formulary (BNF), which gives information about medication, should be DS0000066589.V375065.R01.S.doc Version 5.2 Page 27 Island Place 3 4 YA20 YA30 5 6 7 YA33 YA33 YA42 obtained to support staff in their knowledge of the medicines they are administering. Medication charts supplied by the pharmacy and medicine labels should accurately state the time of day when medicines are taken. Management and staff should continue to monitor standards of cleanliness in the home, and support people who live there to maintain good levels of cleanliness in their own flats. The provider should consider employing a cook or extra staff at periods of the day when food has to be prepared and cooked. The provider should consider providing a dishwasher for the main kitchen, to reduce the time staff spend in the kitchen undertaking kitchen duties. Staff should continue to remind people who live at Island Place, and who smoke, to only smoke in the designated smoking areas. Island Place DS0000066589.V375065.R01.S.doc Version 5.2 Page 28 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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