Inspection on 09/07/09 for Old Oak Road, 20

This inspection was carried out on 9th July 2009.

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

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

Old Oak Road, 20 20/08/08

Old Oak Road, 20 31/01/08

Old Oak Road, 20 16/07/07

Old Oak Road, 20 04/05/06

Old Oak Road, 20 28/09/05

Old Oak Road, 20 06/01/05

Old Oak Road, 20 11/08/04

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Ashlong House

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Old Oak Road, 20 Old Oak Road 20 Old Oak Road Acton London W3 7HL Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 9th July 2009 09:00 Old Oak Road, 20 DS0000019140.V376297.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. Old Oak Road, 20 DS0000019140.V376297.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 Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Oak Road, 20 Address Old Oak Road 20 Old Oak Road Acton London W3 7HL 020 8740 1296 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) info@yarrowhousing.org.uk Yarrow Housing Ms Martyne Rosaria O Reilly Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Old Oak Road, 20 DS0000019140.V376297.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. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 20th August 2008 Date of last inspection Brief Description of the Service: 20 Old Oak Road is a registered care home providing accommodation and personal care for six men and women with a learning disability. At the time of this inspection, one male and four women were living in the home. The home is located in a residential area of Acton and there are good transport links with the community facilities in Hammersmith and Shepherds Bush. Shepherd’s Bush Housing Association owns the property and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home provides a good standard of accommodation. It is fully accessible to people with a physical disability and people with limited mobility, including those who use a wheelchair, with lift access to the top floor. The weekly fee for the home is £1233.00 Old Oak Road, 20 DS0000019140.V376297.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 2 star. This means the people who use this service experience good quality outcomes. Throughout this report the word we will be used as meaning the CQC Care Quality Commission. This unannounced inspection took place on Thursday 9th July 2009; we spent 4.00 hours visiting the home. We spent time talking to all of the five residents, the registered manager, a deputy manager and 2 members of staff. We checked the care records of two residents and all medication and finance records were looked at. We had a full tour of the home and looked at all resident’s bedrooms. Old Oak Road has had some redecoration and we were told by the registered manager that the cyclical plan is being completed throughout the home. The home was in a good state of repair and residents told us they are happy with the décor in the home. 6 requirements set in August 2008 have all been fully met, 2 new requirements have been set from this inspection. We will make reference to the AQAA Annual Quality Assurance Assessment throughout this report. What the service does well: All of the residents are up to date with their person centred planning reviews, the records looked at were relevant and up to date. We looked at two residents PCP reviews that were very informative showing photographs and pictures of what support each individual required. One of the residents has their PCP on a DVD showing them participating in activities of their choice in the home and in the community. The organisation has recently won a award called ‘What we are Proud Of’ for their use of multimedia, people that use the Yarrow services have been supported by a member of staff to use different multimedia to do their PCP’s. We spent time looking at the new summarised care plans that the registered manager and staff have put together to show what support each resident Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 6 requires. The summaries have photographs included of each resident and are very precise about the individuals needs. We were told by the registered manager that the organisation has commended the team and is now requesting all Yarrow homes put the summarised care plans in place. We were told by two resident’s that they are happy living at Old Oak Road. We spent time with 2 residents being shown their bedrooms and talking about the assistance they receive from staff, both residents told us they are happy with their bedrooms, that the food is good and they like the staff. What has improved since the last inspection? What they could do better: Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 7 We spent time looking at all communal areas of the home, the kitchen units are now looking unkempt and doors are starting to come loose and fall off. The kitchen has been in place for over 15 years and does now require replacing. We looked at the medication records for all of the residents living at the home. There is a need that any information regarding medication changes and medication that is not given daily must have the information recorded on the reverse of the medication administration record. We spent time in the garden that is situated at the rear of the home. The garden is big with a lot of unused space; it would be of great benefit if the organisation funded a sensory area in the garden that could be used by all residents. The garden has been tidied up since the last inspection and the residents have now got a small area that they are growing plants and vegetables in. 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. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 8 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 Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 9 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): Standards 1, 2 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home understands the importance of having sufficient information when choosing a care home. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. EVIDENCE: Comments from people that use the service. ‘I like living here’. ‘I am happy living here, I like my bedroom’. We looked at the statement of purpose and service user guide, the statement of purpose has been updated and does now include all information on the aims and objectives and philosophy of Old Oak Road. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 10 We looked at records in two resident’s files that show that their needs are assessed and reviewed regularly. There was a lot of information in each of the two resident’s files. The registered manager and staff have recently produced a summarised care plan to show in brief what each person requires to be supported in the home. We also looked at Person Centred Plans and PCP reviews that show the home constantly reviews residents care and social needs. We looked at risk assessment records that worked in conjunction with the PCP records and all identified risk areas had an action plan in place to reduce or minimise any risk. We looked at two resident’s agreements; the records were up to date and are revievewed annually. Both records were signed and dated by the residents. All original contracts are kept at the Yarrow head office. Old Oak Road, 20 DS0000019140.V376297.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): Standards 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 service knows the preferred communication style of the individual, and will use proven methods that enable the person to lead a full life that promotes independence and choice. Care plans are person centred are written in plain language and are easy to understand. EVIDENCE: Comments from people that use the service. ‘I am helped by staff, they are really nice’. We looked at two residents files; both included Person Centred Plans with lots of reviewed records. The PCP plans are informative and relevant to each individuals needs. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 12 The PCP plans do reflect the aims and aspirations of the residents; one showed that the individual would like to go on holiday to Tobago to visit distant relatives; the resident has been there twice. Another resident had that they would like to go visit their girlfriend; records show they do this on a weekly basis and their girlfriend also visits the home every week. The PCP plans do reflect the individual’s health and social care needs and how the staff are meeting each persons needs. The PCP’s were in pictorial formats and also on DVD, showing how the individuals are involved in their Person Centred Plans. Staff was seen to promote the residents independence assisting them when requested and not telling the residents what to do. We spent time looking at the new summarised care plans that the registered manager and staff have put together to show what support each resident requires. The summaries have photographs included of each resident and are very precise about the individuals needs. We were told by the registered manager that the organisation has commended the team and is now requesting all Yarrow homes put the summarised care plans in place. We looked at the finances of two residents; all five residents money is managed by the staff and kept in the office safe. The financial transaction sheets looked at had all of the money spent and receipts were in place for all expenditures. The correct balance of cash was in each residents tin with the correct balance recorded. We were told by the registered manager that the money is checked on a regular basis by her or one of the deputy managers. We saw in each resident’s daily activity and social chart that it included laundry and room cleaning tasks, we were told by one resident that they are assisted to do laundry every week. We also saw that one resident likes to cook, we were told by staff that the resident is asked at meal times if they would like to cook. We were told by the registered manager that residents are spoken with regarding participating in the organisations recruitment procedure, one resident did take part in the past. We looked at the risk assessments for two resident’s, all of the risk areas identified in the care plan had an action plan in place to inform staff of the risk and how to eliminate or minimize the risk. The risk assessments did work in conjunction with the care plans. Old Oak Road, 20 DS0000019140.V376297.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: Standards 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 service has a strong commitment to enabling residents to develop or maintain their skills, including social, emotional, communication and independent living skills. Individuals are supported to identify their goals and work to achieve them. EVIDENCE: Comments from people that use the service. ‘I go out every day and spend the weekend at my dad’s’. ‘I like to visit my girlfriend we have lunch together here and at her home’. ‘I like the food here’. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 14 We looked at the Person Centred Plans of two residents; the records contained a lot of information about each resident’s likes, dislikes, hobbies and leisure interests. We also looked at the daily records and activity programmes for all five residents that had information about what activities they had done daily that included attending local cafes, going to the local community centre called the Gate, attending dancing classes, art classes, discos, eating out, and for two residents having beauty treatments that include massage and getting there nails done. One resident has a computer in their bedroom that has been specially adapted to meet their needs and the software installed for their enjoyment. The resident was happy to show us their computer and signed to communicate they are happy with it. We discussed staff input to provide an appropriate activity programme; we were told by the registered manager that there are now no difficulties in escorting residents out as they are fully staffed except for one day service vacancy. The registered manager did state that there is a resident vacancy at this time and staffing would have to be reviewed when a new resident moves into the home. We looked at the rota for staffing in July 2009 that shows there is adequate staffing at this present time to provide appropriate activities for all residents. We looked at the contact information for two residents, two residents contacts their girlfriends on the telephone on a regular basis and also visit them in their homes. Their girlfriends also visit Old Oak Road. One resident goes to spend time with their dad at the weekends. In discussion with the registered manager we were told that residents are always encouraged to continue relationships with their family and friends. We were told by the registered manager that the big shopping is done weekly and staff and residents will shop more regularly for perishable items. We saw a lot of fresh food at the home. We were told by residents that they enjoy the food, one resident has a special diet and staff will liaise closely with them to make sure they are provided with variety. We saw the weekly menu that is in the kitchen; residents choose the menus at their weekly house meeting. The AQAA form completed does go into detail about the different diverse needs of the residents and how staff do try to provide a varied menu. Old Oak Road, 20 DS0000019140.V376297.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): Standards 18, 19, 29 and 21. 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. Personal assistance is responsive to the varied and individual needs and preferences. Residents have access to healthcare and remedial services. EVIDENCE: Comments from people that use the service. ‘I am happy with the help from staff, they are really nice’. People receive personal and healthcare support using person centred approach with support provided based upon the rights and dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health; nursing and dietary requirements are clearly recorded in each person centred plan. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 16 We looked at two residents files, both included information on what level of support they require. On the day of this site visit staff were seen to be encouraging the residents, personal and healthcare support is provided in a person centred way. All five residents require different levels of support from full support to prompting and assisting an individual; the information was clear in each PCP plan looked at. We saw information on how the home had liaised with other professionals including speech and language therapists, psychologists, psychiatrists and social workers. All of the residents living at Old Oak Road are registered with a local GP. We looked at the medication records for all five residents that were well recorded. We looked at the storage of medication that is in the office, the registered manager must make sure that all bottles of medicine opened have the date of opening recorded on the label, to make sure that residents are not given out of date medicine. We looked at staff training records and all staff has attended medication training. We looked at the medication administration information for one resident that states medication should be taken on different days; there was no information on the reverse of the MAR sheet to explain the frequency. The registered manager told us that she will liaise with all staff to make sure that they complete the information on the MAR sheet. We looked at two resident’s files and each contained a Health Action Plan that had been completed in March 2009, these plans show that the resident is up to date with all health checks including an annual health check by GP, optical, dental and other relevant health care checks. We saw weekly weight charts in both files looked at; both residents weight was stable at this present time. Old Oak Road, 20 DS0000019140.V376297.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): Standards 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 complaints procedure is supplied to everyone living at the home and displayed on the notice board. Training for staff in safeguarding is arranged by the home including other training in dealing with physical and verbal aggression. EVIDENCE: Comments from people that use the service. ‘I would speak to staff if I was not happy’. ‘I have no complaints I am happy’. We looked at the complaints file that had no complaints logged, however the information was in place to show how the staff would deal with any complaint raised. We were told by the registered manager that all staff is aware of what to do if a complaint or issue was raised. The complaints procedure was on the resident’s notice board in the dining room. The complaints procedure is available in different formats including pictorial. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 18 We spent time discussing the safeguarding policy and procedure with the registered manager and one of the deputy managers. The registered manager has put in place the organisations safeguarding policy and procedure and the local authority procedure for staff to follow if an incident occurs. We looked at the training records of all staff and all staff has attended safeguarding training. We spent time talking to staff that were very knowledgeable about what they would do if an incident occurred in the home. Old Oak Road, 20 DS0000019140.V376297.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): Standards 24, 25, 28 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 physical environment that is appropriate to the specific needs of the people that live there. EVIDENCE: Comments from people that use the service. ‘I like my bedroom, I chose the colour of the room’. ‘I like my bedroom it is comfortable’. One resident that we were shown their bedroom by them, signed to say that they like their bedroom and it’s comfortable. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 20 We had a full tour of the home and all areas were seen. Old Oak Road cyclical redecoration programme has started with four of the six residents bedrooms having been decorated. We were told by the registered manager that the other residents bedroom and the vacant bedroom is planned to be completed soon. All communal areas have been decorated and the cracks in the walls have all been repaired. There are new curtains in the lounge that have been especially made; we were told by the registered manager that new curtains are on order for al other areas. We spent time in the garden that is situated at the rear of the home; the garden has been tidied up since the last inspection in August 2008. It would be of great benefit to the residents if some of the large garden area was used as a sensory area so that residents that do not go out into the community as much as other’s could spend time in the garden. There is a small area of the garden that is used for residents to grow vegetables, they are currently growing tomatoes. We spent time with three residents in their bedrooms that were seen to be comfortable and had a lot of personal items in place. One resident has a lot of furniture in their room that was bought with them from their flat in the community. The other two bedrooms had a lot of personal items in place and each had a TV. We looked at all communal areas of the home, the lounge was comfortable, and the bathrooms were adequate. The kitchen does now require to be replaced as it looking unkempt and the doors are starting to fall off. The home was clean, tidy warm and bright on the day of this site visit. Old Oak Road, 20 DS0000019140.V376297.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): Standards 32, 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. There is now enough staff available to meet the needs of all residents. Staff rotas take into account the needs and routines of the people using the service. EVIDENCE: Comments from people that use the service and staff. ‘I like the staff here they are nice’. ‘The staff help me, they are really nice’. ‘I enjoy working here; we assist and support all residents to be as independent as possible’. ‘I have had a lot of training and I am up to date with all of the relevant organisations training’. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 22 We looked at the staff rota for July 2009, there was adequate staffing on each shift to meet the care needs of the five residents, and sufficient staffing to provide a full activity programme for all residents especially trips into the local community. We spent time discussing staffing with the registered manager and were told that there is one vacancy in Old Oak Road for a day service worker. There is at present a vacancy of one resident and we were told that the staffing levels would be reviewed when the home is full. We were told by residents that they liked all of the staff. We looked at the CRB information on all staff currently working at Old Oak Road; all disclosures were up to date. We looked at the training records of all staff that show that all staff is up to date with training, there is a member of staff who is currently completing induction training, and there is a new deputy manager that is attending the relevant training. We spent time at the organisations head office in December 2008 looking at staff recruitment records, all of the relevant checks were seen to be in place. All staff recruitment records are kept by the human resources team in safe storage at the head office. The registered manager and one deputy manager has completed an NVQ level 4 and equivalent qualifications; we spent time discussing the continuous training of all staff with the registered manager who told us all staff is up to date with training. Records were looked at showing that staff is attending training and keeping up to date in the organisations training programme. There are currently four of the nine members of staff with an NVQ, we spent time discussing the qualification with the registered manager and was told that the other staff are being nominated to do the NVQ qualification. Old Oak Road, 20 DS0000019140.V376297.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): Standards 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 manager has a clear understanding of the key principles and focus of the service, based on the organisational values and priorities. EVIDENCE: The registered manager has worked in social care for many years and is very experienced; the registered manager is registered to complete an NVQ level 4. We spent time throughout this site visit discussing all areas of running the home, the registered manager is very positive about the care provided by the staff team and discussed the person centred approach that all staff follow making sure all of the residents independence is promoted. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 24 We spent time discussing the organisations quality assurance procedure with the registered manager. We looked at questionnaires that hade been completed by residents, we discussed that advocates and other professionals that work with the residents should also be involved. We saw a lot of positive comments about the care provided at Old Oak Road. The organisation produces an annual survey of all of the homes including Old Oak Road. We were given in formation in the AQAA returned that shows that all health and safety checks are completed on a regular basis. We looked at records for checks for the fire alarm system, tests and evacuation records, safe food storage, water temperatures and gas and electric maintenance, all were seen to be well recorded and up to date. All staff training records were looked at and all staff has completed first aid training. Old Oak Road, 20 DS0000019140.V376297.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 3 2 3 3 x 4 x 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 2 25 3 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x 3 x Version 5.2 Page 26 Old Oak Road, 20 DS0000019140.V376297.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement The registered manager must make sure that all staff is completing the reverse of the MAR sheet to show precise information relating to residents medication. To make sure that they are receiving the correct dosage. The organisation must replace the kitchen units, to provide a safe comfortable environment as written in the statement of purpose. Timescale for action 09/08/09 2 YA24 23 09/12/09 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. Refer to Standard YA24 Good Practice Recommendations The organisation to look at completing work in the garden to make it accessible for residents and improving the environment to make it an area where residents can go safely and spend some quality time. Old Oak Road, 20 DS0000019140.V376297.R01.S.doc Version 5.2 Page 27 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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