Inspection on 14/01/08 for Ryan Q.C. Homes, The Elms

This inspection was carried out on 14th January 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ryan Q.C. Homes, The Elms 15/01/07

Ryan Q.C. Homes, The Elms 16/02/06

Ryan Q.C. Homes, The Elms 26/09/05

Ryan Q.C. Homes, The Elms 30/12/04

Ryan Q.C. Homes, The Elms 17/05/04

Ryan Q.C. Homes, The Elms 15/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Ryan Q.C. Homes, The Elms 10 Repton Court The Arbours Northampton NN3 3RQ Lead Inspector Stephanie Vaughan Unannounced Inspection 14th January 2008 09:30 Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ryan Q.C. Homes, The Elms Address 10 Repton Court The Arbours Northampton NN3 3RQ 01604 411858 01604 499720 laurierqch@aol.com 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) Mrs Margaret Laurie Duggan Mrs Margaret Laurie Duggan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. There is currently one Service User within the category of LD. By agreement there will not be any further admissions of Service Users under the age of 30 years. 15th January 2007 Date of last inspection Brief Description of the Service: The Elms is one of two homes run by Ryan Q.C. Homes and provides personal care for up to three young adults who have learning disabilities. The home is situated in a cul-de-sac in a residential area of Northampton and is indistinguishable from neighbouring houses. The home is a bungalow with all bedrooms single occupancy. Fees are from £667 to £1538 per week - this information was included within the Statement of Purpose. There are costs for extras - hairdressing, toiletries, holidays, some transport, dry cleaning, chiropody and dental charges and personal items such as clothing. The findings of the Commission for Social Care Inspection inspections are discussed at staff and residents meetings. Full copies of the report are available in the home and accessible on request. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.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. Prior to this statutory inspection, a period of two hours was spent in preparation. This comprised reviewing the previous inspection records, reports, the service history and other documentation. The Annual Quality Assurance Assessment and Comment Cards have not been returned to the Commission due to circumstances beyond the control of either the Commission for Social Care Inspection and the provider. The Commission have received no complaints or concerns about this service. However there has been one allegation relating to the Safeguarding of Adults, a full investigation was conducted and no evidence was found to support the allegation. The Commission have a focus on Equality and Diversity and issues relating to this are included in the main body of the report. This site visit to the home was conducted over a period of three and three quarter hours during which the inspector made observations and spoke to residents and staff. Due to the nature of their conditions some of the residents have limited verbal communication abilities. In these circumstances observation are used to inform the inspection process. Discussion with staff was also limited due to their previous commitments to activities with residents outside of the home. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of two residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. The Manager was not present during this visit, however a Deputy Manager from within the group was present during most of the visit. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 6 What the service does well: Admissions to the home are managed well and people who might wish to move into the home are given opportunities to visit and information to help them make decisions. Each resident has their own care plan; they are involved in the development and review of these. The plans are written in a user-friendly style so that they are easily understood. The plans contain all the right information so that the staff know how the residents like to be cared for. The staff make sure that they do the right checks so that residents can do as much as possible and continue to be safe. Residents are able to make choices about how to spend their time such as home learning, going to college or day centres. They also go out to pubs and restaurants and can go to local churches if they wish. Residents are able to keep in touch with family and friends either by having visitors to the home or visiting others. The staff and residents seem to get on well, residents said that the staff were nice to them and that they were happy living there. Residents are involved in planning the menus and also encouraged to be involved with some of the food preparation. The food provided is usually home cooked and the menu appears to offer a healthy diet. Residents said that they were satisfied with the food provided. The residents are supported to stay healthy and have all the right checks such as going to the dentist. They have access to doctors, other specialists and hospital services when needed. The home has a complaints policy, which is available in the home; there have been no complaints since the last inspection. Residents were able to confirm that they felt safe living at the Elms. The home is safe, spacious and comfortable. Residents have their own rooms and have their own property with them; they can make choices about the décor. Staff are respectful of their privacy. There are enough staff working in the home to care for the residents properly extra staff are available when needed. The staff have the right training to make sure that they can care for the residents properly. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The management need to make sure that residents have information that is up to date such as the Statement of Purpose (a booklet that tells people about the service) and residents contracts. Care plans need to be reviewed more often to make sure that they are up to date and are changed as the residents needs change. The daily records need to have more detail recorded in them to show how residents are helped to make choices in their daily lives. The staff need to make sure that the medication systems are safe and that the records are accurate. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 8 The staff need to make sure that they have a copy of the new local Safeguarding of Adults guidelines and to know what they would need to do in the event of an abusive situation. The management need to make sure that residents can get their money when the Registered Manager is not working. The management need to make sure that the house number is clearly displayed in case of an emergency. Senior staff should have access to the staff files for the purposes of recruitment, staff supervision and training. The residents and their representatives need to be formally consulted about their views of the service and the homes policies and procedures need to be regularly reviewed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.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 Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are appropriately assessed prior to moving into the home ensuring that their needs can be met. EVIDENCE: The service has a Statement of Purpose, which conforms to the criteria specified in schedule 1 of the National Minimum Standards, however this is now in need of review having been last reviewed in September 2006. There have been no new admissions to the home since the last inspection, the individual plans of care for existing residents evidenced that residents have comprehensive assessments to ensure that the service is able to meet the needs of the prospective resident. There was evidence that residents are able to visit the home, view the facilities meet other residents and staff before deciding if they would like to live there. The service has comprehensive admission policies and procedures to ensure that resident’s admissions are managed appropriately and that residents have information to help them make informed decisions about the home. There is Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 11 currently one vacancy and the management are mindful of the need to ensure that any new resident is able to integrate well with the existing residents. Each resident has a contract on file which specifies the terms and conditions of residency. However these are now overdue for review and need to be re issued so that residents have access to up to date information. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have control over their lives to enable them to enjoy a lifestyle that promotes choice and independence. EVIDENCE: Two residents were case tracked both had an individual plans of care which provides detailed instruction to staff about all aspects of residents health, personal and social care needs. There is evidence that these are developed with the residents and that their views are sought about how they wish to be cared for. There is evidence that any restrictions placed on residents are in their best interests and that appropriate risk assessments are in place to support these decisions. Individual plans of care contain information about the management Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 13 of challenging behaviour and provide detailed instruction to staff about how these behaviours are to be managed. There is evidence that both the residents and their families are consulted about the content of the individual plans of care and that the residents have access to a key worker. There is some evidence that individual plans of care have been reviewed on an annual basis, however due the National Minimum Standards specify that individual plans of care should be reviewed at least six monthly or more frequently as required. Individual plans of care contain detailed information about how the residents are to be involved in making decisions within their daily lives such as times of rising and retiring to bed and choice of activity. Outcomes for residents appear to be good for example there is a file, which contains pictorial information about available activities that is used to enable residents with limited communication to make decisions about what they would like to do. There is also evidence that residents are able to choose to opt out of activities should they wish to do so. However in general the daily records do not reflect the level of detail required to demonstrate compliance with the Mental Capacity Act 2005. The individual plans of care contain detailed and comprehensive risk assessments pertaining to the resident’s activities and daily lives, appropriate controls are in place to maximise independence and yet maintain the residents safety. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s social, religious and recreational interests are effectively promoted in accordance with their known lifestyles and given capacities. EVIDENCE: Individual plans of care evidenced that residents have access to educational opportunities through attendance at college and one to one tuition in basic life skills. Residents are also able to attend local day centres where they are able to pursue their interests. Residents also access the local community through use of local shopping and leisure facilities such as going to pubs and restaurants and getting take away meals. Residents are supported to maintain their faith should they wish to do so and are able to receive their chosen visitors to the home. Residents are also Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 15 supported to visit family members and to celebrate seasonal and family events such as Christmas and birthdays. Residents confirmed that they were able to maintain family links and develop friendships. Individual plans of care are person centred and promote the equality and diversity of the individual. They are produced in easy read formats to maximise the resident’s access to information that is recorded about them. Routines appear to be flexible within the constraints of planned activities. The staff are mindful of the residents privacy and were seen to knock and await permission prior to entering residents rooms. The staffing arrangements ensure that there is always a female carer on duty to provide intimate care for female residents. Risk assessments are in place regarding the absence of privacy locks on bedroom doors and there is evidence that residents have been consulted about their wishes regarding this. Individual plans of care demonstrated that residents are supported to manage their personal mail and that appropriate risk assessments are in place. Staff were seen to relate well to residents and to address them by their preferred name. Residents were able to confirm that the staff were nice to them. Breakfast service was viewed and seen to comprise of a choice of cereal toast and jam with fruit juice and a choice of tea or coffee. The menu was also viewed and appeared to comprise a balanced diet providing three meals a day with snacks and drinks in between. There is the option to have a cooked breakfast at weekends and a Sunday roast is provided, the food is generally home cooked. Residents meet on a weekly basis to plan the menu, their food preferences are well documented in the individual plans of care. There is evidence that residents are involved in the preparation of food according to their wishes and capability. Residents have access to appropriate aids and adaptations to promote their independence. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have an individual plan of care, which demonstrates that, their health; personal and social care needs are generally met. However shortfalls in the medication systems have the potential to put residents at risk. EVIDENCE: Residents appeared well presented and were able to confirm that they felt well cared for. Individual plans of care contained detailed instruction to staff about the resident’s wishes in the way that they are cared for and preferred routines. There was comprehensive and detailed instruction to staff about personal care such as presentation, hair care, oral care and nail care. The Staffing mix is reflective of the residents’ age, gender, race and culture, existing residents are both white British with English as their first language. Residents have access to a wide range of health care specialists such as Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 17 General Practitioners, specialist nurses, Speech and Language Therapists, Community Learning Disability Teams and hospital services. There is evidence that residents have routine health checks such as eye tests and visits to the dentists. Medication is generally managed well and stored appropriately. It is obtained from a high street chemist in a monitored dose system with associated Medication Administration Records. However the practice within the home has been to develop their own medication records which involves the transfer of information from the 28-day record supplied by the chemist to a 31-day record. This practice not only has the potential to introduce errors to the administration system, it also means that the record of administration is out of synchronisation with the amount of stock supplied thus making it difficult to check that the balance corresponds to the remaining stock. In addition the homes record has no system of coding so that staff are unable to record why a particular medicine was not given as prescribed. On examination of one record it was noted that one dose of an important medication had not been signed to show that it had been given, because of the lack of a stock control system it was not possible to determine whether the medication had been omitted or just not signed to show that it had been given. On reflection the deputy manager identified that the resident may have been on a home visit and the medication had been given whilst at home. Because there was no coding system included in the homes medication record there was no way to ensure that the staff involved were able to make an appropriate record of this. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a roust complaints procedure and good staff awareness and attitudes regarding Safeguarding Adults so that residents felt safe and were protected. EVIDENCE: There have been no complaints about this service since the last inspection. The service has a comprehensive complaints policy and there are compliant leaflets available in the main entrance. Residents and their relatives are able to make complaints about the service should they wish to do so. Information about the complaints policy is also included in the Statement of Purpose and welcome pack supplied to new residents. There has been one Safeguarding Adults allegations about this service since the last inspection this has been investigated and found to be not upheld. Staff spoken to were able to confirm that they had had training in the Safeguarding of Adults since the last inspection. However the service does not seem to have received a copy of the new Safeguarding Adults guidelines issued by the Local Authority and has agreed to obtain this and ensure that they are familiar with the content. Residents spoken to were able to confirm that they felt safe living at the home. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 19 The service supports residents to manage their own money; this was not checked on this occasion, as the Registered Manager was not available. Limited staff have access to residents money and associated records to ensure accuracy and accountability. The Deputy Manager confirmed that in the absence of the Registered Manager residents could access money from the petty cash. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing residents with a safe and comfortable place to live. EVIDENCE: The premises are suitable for their stated purpose, being a large bungalow within a residential setting. The premises are well maintained; the garden areas are accessible and safe. No hazards were identified; fire doors are fitted with automatic closure devices. The premises are clean, well ventilated, heated and have appropriate lighting, there are adequate supplies of hot water. Following a Requirement made at the last inspection radiator guards have now been fitted to radiators with high surface temperatures. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 21 The management have agreed to ensure that the number of the house is clearly displayed to ensure that in the event of the emergency services being required that there is no unnecessary delay in locating the premises. Residents have access to a large lounge, dining room with an additional conservatory, all facilities are located on the ground floor and are accessible to wheelchairs. Furnishing and fittings are of a domestic nature and provide residents with a homely and comfortable place to live. Each resident has their own bedroom, these are fitted with wash hand basins, bath and shower rooms are in close proximity. Bedrooms are appropriately furnished and evidence that residents are able to personalise their rooms and have their own possessions around them. There was also evidence that residents are involved in decisions about the décor of the home and residents were able to confirm that they were comfortable living there. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service employs appropriate numbers of inducted and trained staff to ensure that the residents needs are appropriately met. EVIDENCE: Staffing levels appear to be adequate to meet the needs of the existing residents. There is one sleeping member of staff on duty at night and at least one carer on duty during the day; extra staff are available for activities and outings as required. Due to the absence of the Registered Manager we were unable to access staff files on this occasion. However there was evidence with the Statement of Purpose that most of the staff have achieved National Vocational Qualifications in Care level 2 and 3. The deputy manager is due to complete the National Vocational Qualification level 4 in the near future. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 23 Through discussion with the deputy manager it was established that there have been no staff recently employed in the home. However the management are mindful, following a previous Requirement, of the need to ensure that all staff have appropriate pre employment checks and that these are documented within the staff files. In the absence of access to staff files we were unable to view staff training records. However the Deputy Manager was able to confirm that following Requirements made at the last inspection staff training has been reviewed and that all staff have now had fire safety training and training in the management of challenging behaviour. He was also able to confirm that the service has an induction programme for new staff and that staff receive mandatory training such as First Aid, Fire Safety, Basic Food Hygiene, Movement and Handling and the Safe Administration of Medication. Staff also have access to training specific to the needs of individual residents such as Epilepsy Awareness. The Deputy manager was also able to confirm that following a recommendation made at the last inspection senior staff have had training in staff supervision and appraisal and that formal and regular staff supervision has now commenced on a regular basis. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents interests were enhanced through the service being run in an organised manner, which satisfactorily promotes their health and safety EVIDENCE: The Registered Manager is qualified, experienced and competent to manage the service, however she is currently not listed on the duty rota, due to circumstances beyond her control. There is a deputy manager in post and a deputy manager form another home within the group, both deputies are taking on extra responsibility for the management of the home and are nearing Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 25 completion of their National Vocational Qualification in Care level 4. Responsibilities are in the process of devolved. The management have demonstrated compliance with previous requirements all three having been met. Due to the recent unavoidable absence of the Registered Manager there has been some slippage in the routine managements of the home, such as timely completion and submission of the Annual Quality Assurance Assessment and associated comment cards, review of individual plans of care, review of policies and procedures, Statement of Purpose and circulation of satisfaction surveys to residents and relatives. However other Quality Assurance systems continue, staff continue to complete various audit sheets that demonstrate that in general the management of the home continues in an organised and safe manner. The fire records were reviewed and found to be in good order with routine checks being conducted on a regular basis. Certificates were also available to demonstrate that the fire alarm systems and emergency lighting have been serviced within the last few months. There was also evidence that appropriate kitchen records were being maintained to ensure that fridges and freezers are maintained at safe temperatures. Appropriate risk assessments are in place for individual residents and for the environment and accident records are maintained. Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 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 3 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 2 X 3 X 3 X X 3 X Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 27 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 13.2 Requirement Medication systems must be reviewed to ensure that they are safe, enable appropriate stock control and provide accurate and complete records of administration. Timescale for action 01/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA5 YA6 Good Practice Recommendations The Statement of Purpose should be reviewed to ensure that residents and their representatives have access to accurate and up to date information. Resident’s contracts should be reviewed and reissued to ensure that residents and their representatives have access to accurate and up to date information. Individual plans of care should be reviewed at least six monthly or more frequently if required to ensure that staff have up to date information about how the residents wish to be cared for. Daily records should have greater detail recorded to show how residents are enabled to make decisions in the course of their daily lives. DS0000037246.V356364.R02.S.doc Version 5.2 Page 28 4. YA6 Ryan Q.C. Homes, The Elms 5. 6. 7 YA23 YA23 YA24 8 9. 10 YA34 YA39 YA42 A copy of the new Local Authority Guidelines on the Safeguarding of Adults should be obtained and ensure that staff are familiar with the content. Arrangements should be reviewed to ensure that residents have reasonable access to their personal finances. The house number should be clearly displayed to ensure that in the event of the emergency services being required that there is no unnecessary delay in locating the premises. Arrangements should be reviewed to ensure that senior staff have access to staff files in the absence of the Registered Manager. Residents and their representatives should be consulted on their views about the service and the results used to inform service development. Policies and procedures should be reviewed on an annual basis or more frequently as required Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ryan Q.C. Homes, The Elms DS0000037246.V356364.R02.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!