Inspection on 28/07/09 for New Court Place

This inspection was carried out on 28th July 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

New Court Place 05/08/08

New Court Place 08/09/07

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

Key inspection report CARE HOME ADULTS 18-65 New Court Place 99 Whitehouse Avenue Borehamwood Hertfordshire WD6 1HB Lead Inspector Claire Farrier Key Unannounced Inspection 28th July 2009 11:00 New Court Place DS0000070238.V376873.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. New Court Place DS0000070238.V376873.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 New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Court Place Address 99 Whitehouse Avenue Borehamwood Hertfordshire WD6 1HB 020 8238 6990 020 8238 6991 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) www.grooms-shaftesbury.org.uk Livability Elizabeth Wehrle Care Home 24 Category(ies) of Physical disability (24) registration, with number of places New Court Place DS0000070238.V376873.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 with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Physical Disability - Code PD The maximum number of service users who can be accommodated is: 24 5th August 2008 Date of last inspection Brief Description of the Service: New Court Place is a care home with nursing, providing accommodation and care for 24 adults between the ages of 18 and 65 years of age who have physical disabilities. It is owned by Livability, which is a voluntary organisation. New Court Place is a three storey purpose built building. It is located in a quiet residential area of Borehamwood, about a quarter of a mile from the town. The home has been built and fitted out to high specifications that exceed those required by National Minimum Standards. The accommodation is arranged in three units on the ground and first floor that are designed to resemble an indoor street, and each resident has a large self-contained studio, with a kitchenette and ensuite shower room. The home has a patio garden accessed from the ground floor dining room. The home is fully accessible for the people who live there. The Statement of Purpose and Service Users Guide provide information about the home for referring professionals and prospective clients. Information on the fees charged was not available on this occasion. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We spent one day at New Court Place, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. We talked to four people who live in the home. We also talked to some of the staff and we looked around the home. We looked at some of the records kept in the home. We also looked at a sample of care plans so that we could see how people are involved in planning their own care and support. The manager was on leave at the time of this inspection, and we discussed what we saw during the day with the Head of Care. The manager sent some information (the Annual Quality Assurance Assessment, or AQAA) about the home to CQC before the inspection, and her assessment of what the service does in each area. Evidence from the AQAA has been included in this report. What the service does well: The AQAA states, “What our service does well is that all residents are consulted on all aspects of their care and are involved in formulating their plan. The care provided is often commented as being of an exceptional standard by professionals who use the service where they have the opportunity to compare to other service provisions.” The people who we spoke to said that regular residents’ meetings take place, and they are make choices and decisions about their lives in the home and their social activities The home provides a good quality of personal care and health care. There is good relationship between the staff and the people who live in the home. The staff are aware of each person’s individual needs and preferences, and they support them to make appropriate choices and decisions about their lives in the home. Everyone who we spoke to said that they are happy in their home. A visiting GP said that the home provides a very good quality of healthcare, and works well with professionals. The GP loves visiting the home. The design of the home enables the residents to live as independently as possible. The home has a stable staff team of nurses and care workers, who are experienced in working with young adults with physical disabilities. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 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 home has sufficient information on the needs of the people who live in the home, and access to appropriate services and training to enable their needs to be met. However the information that is available for people who are considering moving to the home is not sufficient to enable them to make an informed choice. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) states that the Service User Guide has changed several times during the last year due to changes in the organisation, and the service has produced a leaflet that individuals can be sent relating to the unit and the organisation. Following this inspection, Livability sent an action plan to CQC. This stated that the Statement of Purpose and Service Users Guide have been reviewed four times in the last year. It stated that there is a current copy held in the manager’s office. However the Service Users Guide and Statement of Purpose that were displayed on the notice board in the manager’s office during our visit have not New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 9 changed since our last inspection, and revised versions were not found when we asked for them. Livability has reviewed its website to advertise the units and the services. The Livability website www.livability.org.uk has a link to the Service Users Guide. But this is two page leaflet that contains a brief description of the service, but does not contain all the information that is required so that people can make an informed choice about moving to the home. This leaflet is also available in the home. The leaflet states, “New Court Place is a registered residential care and nursing home for 24 adults with profound physical and learning disabilities.” However the home is registered with the Commission as a service for people with physical disabilities, and it is not registered for people with learning disabilities. The website does not provide sufficient information to comply with the requirements for either the Statement of Purpose or the Service Users Guide. The AQAA states that what the service could do better is to try and find a more suitable format for the Service Users Guide, and that the plan for the next 12 months is to produce a powerpoint presentation on the computer for individuals to visually watch. However in the meantime the information that is available for people who are considering moving to the home is not sufficient to enable them to make an informed choice. No one has moved into the home since the last inspection, but one person has been preparing to move in. We saw the information that the home has about this person’s needs, that included a full assessment from the residential college that they were attending and an assessmenbt and updates from the person’s social worker. The manager has carried out an assessment, and handwritten notes from this were in the file. The person has visited the home on two occasions, and it was recorded that they expressed a preference for New Court Place over other services that they visited. A contract format was completd that included the fees, and the agreement of the local authority for a six week trial period. All the residents who we spoke to said that the staff are competent to meet their needs. The home has a stable staff team with access to appropriate training. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 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 live in the home are actively involved in planning their own care and are consulted on every aspect of community life in the home. EVIDENCE: The care plans are maintained by computer, and the care staff and nursing staff are able to add the details of the care provided each day and to update them as required. We looked at the care plans of three people, and the evidence of care provided for them was tracked through their records. The care plans provide sufficient information on all aspects of each person’s care to enable the staff to meet their needs. Everyone has a moving and handling assessment, and risk assessments are in place for people who need to use bed rails. A risk assessment for one person for going out in their wheelchair was provided by the wheelchair service. The activities co-ordinator undertakes risk New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 11 assessments of local places such as the cinema to ensure that they are suitable for people to visit. The Annual Quality Assurance Assessment (AQAA) states that people are consulted on all aspects of their care and are involved in formulating their plan. They are made aware that they can change their mind and and encouraged to discuss this with their keyworker if necessary. The AQAA stated that there are summary sheets for the main careplan which are held in the residents’ rooms. We saw some examples of these that have a clearly written summary of each person’s needs and daily routines. The people who we spoke to said that regular residents’ meetings take place, and they are make choices and decisions about their lives in the home and their social activities (see Lifestyle). We saw minutes of the last residents meeting in May 2009, when the items discussed included food, staff changes, activities, and any concerns and worries that people had. The people who we spoke to said that they have choice and control of their finances and can access their money as they wish to. One person has responsibility for all their own finances, and good records are maintained for personal money that is kept in the office. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 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. The people who live in the home are encouraged to make choices for their activities, and to be involved according to their abilities in developing their skills for independence. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated that Livability has undertaken an audit of all aspects relating to the residents choice, and this showed a positive response. All residents are able to discuss with their care manager at their reviews how they would like to fill their free time and they then discuss how this can be achieved. Activities are organised across the seven-day week. The activities schedules New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 13 include college courses, IT, pony trapping, wheelchair dancing, crafts and music. Several residents used the computers for Internet access and playing games during the inspection. New Court Place has its own wheelchair accessible transport to take individual service users or groups to events. There are activities and workshops available in the centre and an information board that displays the activities within the home. The activities manager has recently left, and there is now only one activities co-ordinator in the home. We spoke to some of the residents who were in the activities room, and they all said that they are able to do most of the things that they like to do. Last week some of them went to a disco at the Arts Depot in Finchley, and they were out until midnight. There are several trips to Southend during this month, so that everyone is able to go on one. One person said that they enjoyed the drama therapy, but this has now stopped. We were informed that this was ended following a review of the activities in the home, and that there are now additional days out that are of benefit to more people. The people who we spoke to told us that they visit their families, and their families can visit them. Two people who we spoke to were planning holidays with their families. Meals are served in a cafeteria style area with adjustable seating and table heights to accommodate a range of needs and equipment. Residents are able to choose from a varied menu with a wide range of options. There has been a change in the staffing and management of the kitchen, and there is now less fried food on offer, and an emphasis on healthy eating. The people who we spoke to were in favour of this, and said that they did not miss the fried food. There is a kitchenette in each resident’s room, and they are able to make their own drinks and snacks if they wish to. There is a hot drinks machine and a water cooler at wheelchair height in the dining room. Everyone in the home requires staff support to eat their meals. The AQAA stated that some residents will have to negotiate a time for their meal and assistance. We observed lunch. It was a social occasion, and the staff supported people to eat as they wished and at their own pace. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 people who live in the home are confident that they will receive a good quality of personal care and healthcare. The procedures for recording and auditing medication do not ensure that people receive the medication that they need in a safe and effective way. EVIDENCE: The home provides a good quality of personal care and health care. There is good relationship between the staff and the people who live in the home. Everyone needs two people to help them with their personal care. The staff are aware of each person’s individual needs and preferences, and they support them to make appropriate choices and decisions about their lives in the home. The residents have a preferred plan of care, which sets out how they wish to receive their personal care. The people who we spoke to said that the staff support and help them as they wish, and treat them with respect. They can choose when they wish to get up and go to bed, and the staff were happy to New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 15 help them to bed late when they returned from a disco at midnight (see Lifestyle). The care plans provide appropriate details of each person’s health needs, including pressure care concerns and monitoring of epilepsy. There are guidelines for managing behaviour, and care plans are evaluated to show that the measures have been effective. In one care plan we saw clear guidelines for managing an assessed risk of pressure sores. We spoke to a visiting GP, who said that the home provides very good healthcare for the people who live there, and the staff work well with visiting professionals. We carried out a spot check of the medication records for the three people whose care we tracked. The Annual Quality Assurance Assessment (AQAA) stated, “We have reviewed the records of all medication administered by the unit in conjunction with the GP to ensure that there is a clear audit trail for the administration of medication. We have changed the pharmacy who supply the medication for our residents which has seen an improvement in the dispensing packaging and made it easier to use. The nursing staff liaise with the pharmist frequently to support the medication requirements of the unit.” We were therefore disappointed to find errors in the medication records for all three people, all of which should have been picked up and corrected by an effective system of auditing. We have found errors in medication in every inspection during the past three years. Each time measures have been put in place to address the specific concerns, but other errors have been found. On this occasion we found Flamazine cream stored in the fridge, although it does not need to be refrigerated, and this was also observed at a previous inspection. The temperature in the medication rrom is recorded every day, but during the recent spell of hot weather the temperature was recorded at between 25˚ and 26˚C for a period of seven days, but there was no recorded action taken to reduce the temperature to below 25˚C. One person had a prescription for ibuprofen to be taken when required (PRN). The recorded audit showed that one had been taken, but this was not recorded on the MAR (medication administration record) chart. One person had diazepam twice a day, but the pharmacy had not supplied sufficient for the morning dose, so the supply for the evening doise was used. This meant that the medication would run out beofe a new supply arrived at the end of the month. But the amount recorded on the MAR chart as given did not tally with the amount of tablets that were available, which gave the impression that on three occasions the MAR chart was signed, but the person concerned did not receive their medication. One person had Bisocodyl to be given weekly, but it had been administered twice a week. The visiting GP confirmed that this has been administered correctly, and the information printed on the MAR chart was wrong. This should have been checked and noticed when the medication was received from the pharmacist, and the error meant that the medication provided was not sufficient to last until the next delivery. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 16 The audits of medication consisted of a count of the tablets provided in the original packaging rather than in monitored dosage blister packs. This did not pick up the errors that we found, and would not pick up on discrepancies in recording. The Head of Care investigated these discrepancies and sent a response a few days after the inspection. The discrepancies with diazepam and bisocodyl were found to be an error in transferring information from the previous MAR chart, and had been administered correctly. The ibuprofen had been administered to the person concerned, but not recorded. Action was taken to reduce the temperature in the medication room, but this was not recorded. There is no evidence that people did not receive the medication that they were prescribed on these occasions, but the recording and auditing needs to be improved in order to ensure that there is no risk of medication errors in the future. New Court Place DS0000070238.V376873.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 live in the home are confident that their concerns are listened to, and that they are safeguarded from the risks of abuse. EVIDENCE: The home has a clearly written complaints procedure. The Annual Quality Assurance Assessment (AQAA) states that no complaints have been recorded since the last inspection. “What we do well is that the residents come to discuss their concerns and are made to feel that they can do this at any time by the person who they are taking to freeing up the time to listen. The residents when able to do this often are looking for how they can resolve an issue themselves rather than a complaint being formulised. As the staff work closely with the residents and their different ways of communicating the staff are aware of changes in body language and the change in a person, they are encouraged to explore possible causes for that including asking if they are unhappy with something.” The residents who we spooke to confirmed that they are able to discuss any concerns that they have, and that these are addressed. Livability has robust policies for dealing with allegations of abuse or neglect. All the staff have training in safeguarding vulnerable people, and those who we spoke to were aware of the whistle blowing policy and who to speak to if they New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 18 have any concerns. The home has good procedures for recording personal finances, that are robust enough to prevent any possible abuse. New Court Place DS0000070238.V376873.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, 29 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. The home provides a comfortable and well maintained environment for the people who live there, and the staff maintain a good standard of cleanliness and hygiene. EVIDENCE: New Court Place was purpose built as a care home for people with physical disabilities. The rooms are designed as studio style flats, each with a bedsitting room, a kitchenette and an en suite shower room with WC. Many of the fittings can be adjusted to suit individual needs. Each person has equipment that suits their needs, including hoists and environmental aids. The rooms reflect individual tastes and interests. The doors to the residents’ rooms lead off wide corridors that are planned to resemble streets. Wide doors, corridors and lifts mean that people who have to spend some time in bed can still access the New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 20 communal areas. All areas of the home are wheelchair accessible. The large recreation and dining area on the ground floor is a sociable space, and the cafeteria style dining area enables service users have access to drinks and snacks. The home appeared to be clean and well maintained and appropriate policies and procedures are in place for the maintenance of hygiene and control of infection. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in the home are supported by a stable staff team who have the experience and training to understand and meet their needs. EVIDENCE: The people who live in the home are supported by a stable team of nurses and care workers. The staff rotas indicate that two registered nurses and seven care assistants work in the morning with one registered nurse and seven care assistants in the afternoon. One registered nurse and three care assistants work at night. A new staffing structure is being implemented, and staff will work both day shifts and night shifts, to ensure that everyone knows the individual residents well. The Annual Quality Assurance Assessment (AQAA) stated that a staffing review has just been completed and recruitment has started to fill posts that have been identified as necessary. Due to recruiting more staff the number of agency staff used has drastically reduced over the last year. However most shifts include part time bank staff. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 22 We looked at the staff files for two members of staff who have been employed since the last inspection. They both contained all the required information to show that the home practices a robust recruitment procedure that ensures the person is fit to work with and protect the vulnerable people in the home. The AQAA stated that 14 of the care staff, 66 , have a qualification in care at NVQ level 2 or above. The Head of Care and the Unit Manager have started their Leadership and Management programme. NVQ qualifications are also available for the housekeeping staff, activities staff and kitchen staff. Training is organised by Livability training department, and everyone has regular updates of the mandatory health and safety training. The staff who we spoke to said that the have a lot of training. Additional information sessions are provded in the home by professionals such as the Speech and Language Therapist and the Community Learning Disdability Team. These are usually arranged to provide information on a person’s specific needs. The staff who we spoke to said that they are supported by the managers and the organisation. There are regular staff meetings, and the supervision records show that everyone has regular one to one supervision. New Court Place DS0000070238.V376873.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed, and the management actively seeks the views of the residents and other involved people in order to ensure that a good quality of care is provided. EVIDENCE: The manager is a qualified nurse. She previously worked at the Chalfont Centre for Epilepsy, and she is a qualified trainer for first aid, infection control and management of epilepsy. The manager and the Head of Care have started the Leadership and Management qualification programme. New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 24 The Annual Quality Assurance Assessment (AQAA) stated that Livability have undertaken a full audit of the services provided by the home, that included seeking the views of residents, staff, visitors and professionals. The data was audited independantly from the unit and was collated into a report in November 2008. We saw this report during the inspection. The proprietor carries out regular monitoring visits to the home. We saw the reports of the three most recent visits. These include checks on records for supervsion, training and residents money. However they do not include discussion with and the views of the people who live in the home. The home maintains appropriate records for the health and safety of the residents and staff in the home. We checked the fire safety records, and the records of water temperatures in the home. The Environmental Health Officer visited the home in May 2009 to inspect the kitchens, and actions have been taken to improve cleanliness and good food hygiene in that area. New Court Place DS0000070238.V376873.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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 2 X X 3 X Version 5.2 Page 26 New Court Place DS0000070238.V376873.R01.S.doc Are there any outstanding requirements from the last inspection? NO 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 YA1 Regulation 6 Requirement A Statement of Purpose and Service Users’ Guide must be available that include current information about the service and about the management and staff of the home. People who plan to move into the service need accurate information about the services that the home provides. Measures must be put in place to ensure that medication is audited effectively, and that any errors in medication are noted and rectified without delay. This will make sure that everyone has the care and medication that they need in a safe and effective way. Timescale for action 31/10/09 2. YA20 13(2) 31/10/09 New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 27 3. YA39 26 The proprietor must include the 31/10/09 views of residents and staff in their monthly monitoring visits to the home. The reports of the visit must include these views. The views of the people who use the service should underpin reviews and developments in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations New Court Place DS0000070238.V376873.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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