Care Home: 138 to 138a Mason Way

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What the care home does well People living at 138 Mason Way are supported by a group of staff who have worked there for some time. This means that tenants and staff can get to know each other and build relationships. All interactions between staff and tenants were seen to be positive, friendly and respectful. 138 Mason Lane provides a clean, comfortable and timely environment for the people who live there. Residents spoken with indicated that they liked their own bedrooms and were seen to choose to spend time there. In a survey, one person commented "I like living here, it`s a nice house. I have friends in here". Tenants are supported to keep their independence and privacy. Each person has a key to the front door and to their own bedroom. Staff support people to have a fulfilling lifestyle and participate in activities in the community and at home. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 What has improved since the last inspection? Person centred planning has been introduced. This means that people using the service can say what their goals are and lead the type of support they want to have. They meet weekly with their key worker to look at how this is working for them. Many of the tenants` bedrooms have been redecorated and tenants have been involved in choosing how this is to be done. The garden was updated after consultation with the people living at 138 Mason Way, a fish pond was added and tenants are involved in maintaining the garden. Information for people using the service about complaints and safeguarding has been produced in an easy read format, making it easier for tenants to access and understand. Staff and tenants attend training on multimedia which will help them to ensure that communication takes place in a way that people can understand and take part in. What the care home could do better: The decoration of communal areas could be better as could the condition of some of the carpets and furniture, to make sure that all parts of 138 Mason Way are maintained to a reasonable standard for the people who live there. Key inspection report CARE HOME ADULTS 18-65 138 to 138a Mason Way Waltham Abbey Essex EN9 3EJ Lead Inspector Mrs Bernadette Little Key Unannounced Inspection 15th June 2009 09:45 138 to 138a Mason Way DS0000017721.V375994.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. 138 to 138a Mason Way DS0000017721.V375994.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 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 138 to 138a Mason Way Address Waltham Abbey Essex EN9 3EJ 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) 01992 769113 01992 769113 redhsngltd@aol.com www.rchl.org.uk Redbridge Community Housing Limited [RCHL] Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 8 persons) Date of last inspection Brief Description of the Service: 138/138a Mason Way is a residential care home for people with learning disabilities located in a residential area of Waltham Abbey. There are eight people living in this home. The primary aim for this home is to support people to lead as independent a life as possible. The accommodation comprises of two semi-detached houses that provide 4 single bedrooms and communal space in each house. Residents of the houses share a rear garden. There is a local bus service to the nearby town of Waltham Abbey and a parade of neighbourhood shops is available close by. Inspection reports produced by the Commission for Social Care Inspection were kept in the office and were made available to residents and their families/ representatives. The project worker provided information from the organisation that the total cost of a placement at Mason Way is £645.75 per week. 138 to 138a Mason Way DS0000017721.V375994.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 stars. This means the people who use this service experience good quality outcomes. This site visit was undertaken over six and a half hours as part of the routine key inspection of Mason Way. Time was spent with the residents and staff and observations and outcomes of discussions are reflected as part of the report. The manager did not return the Annual Quality Assurance Assessment within the timeframe required. This is required to detail their assessment of what they do well, what has improved, and what needs improving and how they plan to do this. It was later completed and submitted by a project worker as the manager was on leave. The information in the AQAA was considered as part of the inspection process and included as part of the report. Prior to the site visit, the manager was sent a variety of surveys to distribute and that asked questions that were relevant for each group, such as for residents, staff, care managers and healthcare professionals. Completed surveys were received from five service users (also called tenants in the report) and two staff at the time of writing this report. A number of staff were spoken with throughout the day. A tour of the premises was undertaken and records, policies and procedures were sampled. The project worker and manager were not on duty but the project worker came on site and was present for the most part of the site inspection. The outcomes of the site visit were fed back in detail and discussed with the project worker and opportunity was given for clarification where necessary. The assistance provided by all of those involved in this inspection is appreciated. What the service does well: People living at 138 Mason Way are supported by a group of staff who have worked there for some time. This means that tenants and staff can get to know each other and build relationships. All interactions between staff and tenants were seen to be positive, friendly and respectful. 138 Mason Lane provides a clean, comfortable and timely environment for the people who live there. Residents spoken with indicated that they liked their own bedrooms and were seen to choose to spend time there. In a survey, one person commented I like living here, its a nice house. I have friends in here. Tenants are supported to keep their independence and privacy. Each person has a key to the front door and to their own bedroom. Staff support people to have a fulfilling lifestyle and participate in activities in the community and at home. 138 to 138a Mason Way DS0000017721.V375994.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. 138 to 138a Mason Way DS0000017721.V375994.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 138 to 138a Mason Way DS0000017721.V375994.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 and 2 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. Prospective tenants can expect to receive enough information on which to base a decision to live at Mason Way and have a full assessment of their needs to ensure that the service can meet them. EVIDENCE: A statement of purpose and service user guide were available. The service user guide included a welcome to Mason Way and provided the reader with a good deal of relevant information in plain language. As neither document was dated, it was not clear how up-to-date their information is. There have been no new admissions to this service since the last inspection. Detailed policies and procedures regarding the admission process were available and included a full assessment of the persons needs, opportunities for them to visit the service and an initial support plan to be in place for when the person first receives a service, in which they will be involved to ensure their immediate needs are met. All surveys received from tenants of Mason Way told us that they had been asked if they wanted to move into this home and one person said they had 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 9 been living there since it opened in 1993. All surveys received from the tenants also told us that they had received enough information about the home before they moved in so they could decide if it was the right place for them. One survey had the comment they showed me round. My mum and dad came with me. The social worker arranged for me to move here. 138 to 138a Mason Way DS0000017721.V375994.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. Tenants are involved in the development of their own personnel plan and supported to make decisions and maintain their skills and independence. EVIDENCE: There is a formal care/support planning system in place to help staff identify the needs of individual service users and to specify how these are to be met by staff. Two support plans were assessed and both contained clear information for staff to follow to meet the tenants needs in everyday practice while supporting their independence. The plans have begun to written from a person centred approach and the project worked advised that all staff are being re-trained to achieve this. The project worker agreed that while risk assessments were available relating to 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 11 certain behaviours or abilities, these could be more clearly identified in the support plan. Support plans included issues such as peoples medication, religious needs and their social interests and showed review. They also identified clear information on outcomes required with specific support details including for example in relation to everyday tasks such as laundry and cooking. Tenants had signed their care plan to demonstrate their involvement. Staff signatures confirmed they had read and were aware of the current plan. Care notes sampled contained good detail and reflected the persons support plan providing a good monitoring tool. These were seen to be used as part of the review process. A pictorial record was available on one tenants file to demonstrate how the person reached the decision to spend extra money of their own to buy things for their bedroom. The project worker confirmed that none of the current tenants were subject to identified restrictions or limitations. Some residents go out independently and while this was not clearly identified in the support plan, risk assessments were in place. Risk assessment were also in place for a number of activities both inside and outside Mason Way that demonstrate that tenants are supported to take appropriately informed decisions and risks. A call system has been fitted in each persons bedroom enabling them to summon assistance at any time. 138 to 138a Mason Way DS0000017721.V375994.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, 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. Tenants are supported to participate in a range of activities, both at home and in the community and to enjoy a healthy diet of their choice. EVIDENCE: A good times we have book was maintained that showed photographs and records of outings and activities that tenants participated in such as walking at Lea Valley, trips to the funfair, long walks and feeding the ducks, attendance at community events including an air show and a local pageant. This also contained recipes that tenants might like to cook. Care documentation, including daily care records, identify that people living at 138 Mason Way take part in a range of daily activities of their choice including paid work, volunteering, going to the hairdresser, dog walking, hydrotherapy 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 13 and attending an art workshop. Some residents have identified additional oneto-one staff hours to support this each week, while others access the community independently. Two tenants spoken with at the site visit advised that they were going away on holiday that day, which they were very much looking forward to. The AQAA advises that tenants are encouraged to maintain links with family and friends and some tenants go holiday with their family, as well as having an annual holiday from Mason Way. Other tenants spoken with were also going out to various activities of their choice, while others were at home doing the laundry. One person advised they didnt feel like getting up early and thats why they were still in their pyjamas late in the morning, and later went out to the library. Surveys received from tenants confirmed that they make decisions about what they want to do both during the day and at weekends. The AQAA states that tenants take a central role in the running of the house for example in doing the shopping, cooking, cleaning, laundry and gardening with staff support and this was observed at the time of the site visit. One person told us that they had got their own breakfast and that they also do cooking. One tenant in each house has responsibility to choose and help cook for the other three tenants one week in four. User-friendly menu planners were displayed in the kitchen to support people to undertake this task and an alternative was available if people did not want the planned meal. 138 to 138a Mason Way DS0000017721.V375994.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Tenants are supported to maintain their health and well-being and to manage their medication safely. EVIDENCE: The manager operates a keyworker system and the named worker was identified in each persons file by a photograph. Support plans identify what support people do and do not need with personal care to maintain skills and independence and also to maintain privacy and dignity. Key worker meetings are held regularly and there is a monthly synopsis of the daily reports as additional monitoring that the persons support needs are appropriately identified and being met. One support plan viewed contained a list of clear instructions to support the person to monitor and manage their diabetes and appropriate actions to take in response to different readings. A separate health section is maintained on each tenant file. On inspection of individuals’ professional visitors record, this 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 15 showed that people have access to a range of health professionals and services e.g. GP, optician, urologist, dentist and there was evidence of medication review. Staff are available to attend all health visits with tenants and the AQAA advises that there is good communication within the team to ensure effective monitoring of tenants health and well-being. One staff member commented in a survey we take all aspects of health and medication very seriously and thoroughly check each stage. We adjust to changing needs of service users. Weight charts show that people are weighed monthly to monitor this aspect of well-being. Support plans contained a list of the current medication the person was prescribed, the reason for having it, the dosage, start date and planned date for review. A monitored dosage has been implemented with staff advice support greater independence for tenants. Medication was safely stored. Records of medication received and administered were appropriately maintained. Tenants medication recording (MAR) charts identified if they were not self medicating, and all had a photograph to support correct identification. Where a person was self medicating, they signed for their weekly medication and this was tallied down to zero with signatures and dates to ensure accuracy. The project worker confirmed that they have designated responsibility for ordering medication, and advised that staff have medication training every three years with monthly competence assessments with the results recorded on the staff members supervision file. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 16 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. Tenants can be confident that their complaints will be listened to and they will be safeguarded by staff knowledge and the supporting information and systems. EVIDENCE: All surveys received from tenants said they would know who to speak to if they were not happy, and all but one person said they would know how to make a complaint. The organisation have responded positively to the recommendation made at the last key inspection to produce complaint and safeguarding policies in an easy read format. An easy read complaints procedure in large print explained clearly how people could make a complaint, with photographs of the person to contact, their telephone number and also information on contacting Social Care. Additionally a new leaflet has been produced by the organisation on complaints and ideas with a tear-off back page for comments that has the organisations address pre-printed on the other side. A system was in place to record complaints including a log with the date, timescales and actions undertaken. This confirmed the information in the project workers AQAA that three complaints had been received. Two of these related to issues between tenants, one of whom has since moved out. The 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 17 third and recent complaint related to an agency worker and was investigated by the agency. The project worker was recommended to ensure that full information on the outcome is received and recorded and evidence in place that the complainant was responded to. The project worker advised of planned improvements such as an audio/visual user-friendly format for the complaints procedure and adult protection information, which they advised will be possible to implement once the current media training course is completed. There is also a proposal to enrol the tenants on an adult protection course to ensure they have full information to promote their safety and well-being. The project worker assisting with the inspection advised that they help with training service users on safeguarding, looking at issues such as what is an acceptable way to speak to people/be spoken to. A training pack and DVD on safeguarding, provided by Essex social services department in 2006, was available. The project worker was recommended to access the current Southend, Essex and Thurrock protocols and guidance. A clear procedure in relation to whistleblowing was available referring to the Public Information Disclosure Act and encouraging staff to challenge bad practice. Surveys received from staff confirmed that they would know what to do if someone had concerns about the home. Staff spoken with confirmed that they regularly attend training on safeguarding and demonstrated an awareness of types of abuse as well as confidence in challenging and reporting this. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at 138 Mason Way benefit from a safe environment that meets their needs. EVIDENCE: 138 Masons Way is set in a residential area within easy reach of local community facilities. The home is made up of two separate, but adjoining, ordinary four bedroom houses. Tenants spoken with confirmed that they had keys to their own bedrooms and also to the front door. Each house has its own open plan lounge/ kitchen/diner, downstairs shower room, laundry and storage facilities. One house has a downstairs bedroom to accommodate the specific needs one of the tenants. A room in each of the houses previously used by staff is in the process of being refurbished to provide an additional space for tenants, for example for activities. An addition 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 19 to the premises includes a large staff office and sleeping in and shower/toilet facilities, and which has a separate entrance from the tenants houses. Tenants have the use of a communal garden which the project workers AQAA confirms was redesigned and updated after consultation with the people who lived there. The laundry room in each house is appropriately equipped and a resident in one of the houses was busy doing their laundry. Each person has their own bedroom and some of these were viewed with the tenants consent. One person told us that their bedroom had just been done, that they had been able to choose their own colours and things to put in there and said they were very pleased with it and had worked hard to get it done. Other tenants spoken with also told us that their bedrooms had recently been redecorated and that they had been involved in choosing colour schemes etc. People confirmed they were satisfied with their individual bedroom and one person said they had my own television and video and I like to spend time there watching my own things. Furniture and decor in some communal areas was tired and staff told us that they are involved in ongoing discussions with the property maintenance contractors to determine who was responsible, so this could be addressed. Carpets in communal lounge/dining areas were clearly of good quality, advised by staff as having been replaced less than two years ago, but were stained. Surveys received from tenants varied in their views as to whether the home is clean and fresh with some people indicating never, some usually and some always and one person did comments about the stained carpets. Overall, the premises were clean, safe and maintained to a satisfactory level. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 20 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 and 35 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. Tenants can expect to be supported by a competent and stable staff team that promotes consistency of care. EVIDENCE: Staff spoken word advise there is a stable staff team and there has been no agency staff used at Mason Way for some years, with regular relief staff providing cover as was seen in practice. Staff and residents spoken with and information received from surveys indicate that staffing levels are appropriate to meet the needs of the current tenant group. Rotas reviewed demonstrate the staff on duty, the person in charge of the shift and the total hours worked, and are recommend to identify the actual times that staff on duty. It was identified that while a recently reviewed risk assessment was in place in relation to lone working for staff, no risk assessment was in place relating to residents being alone and unsupervised in the houses and that this may need to be considered. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 21 The project worker advised that of seven support staff, two staff have completed NVQ level II, three have just completed NVQ level III and are waiting to be signed off and another staff member is waiting to commence NVQ level II. Files reviewed at the last key inspection found that the recruitment practice was robust and all required references and checks had been undertaken. Staff spoken with confirmed the information in the AQAA that no new staff had been employed since that time. Surveys from staff confirmed that their employer carried out checks such as criminal record bureau checks and took up references before they started work. The project workers AQAA identifies that each team member would receive an induction before starting work under record of induction was available on a file sampled. Staff spoken with confirmed that they had been provided with a full induction. Surveys received from staff indicated that their induction generally covered the things they needed to know to do the job when they started and that they are being given training that is relevant to their role and helps them to understand and meet the individual needs of the people they support. Staff spoken with confirmed that they have really good access to training, both mandatory and other courses such as autism that relate to their personal development plan to keep their skills relevant and develop their knowledge base. One person said our training is thorough and well monitored. A record of training provided to staff by the organisation showed that all mandatory training courses were included in addition to other relevant topics such as equality and adversity and support planning. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 22 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, 41 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. Tenants can expect a well-run service that is increasingly seeking their views and promotes their best interests. EVIDENCE: The current manager has been appointed since the last inspection and is not yet registered with the Commission. The manager was not available at the time of the site visit but the project worker assisted throughout. The AQAA was completed by the project worker and advises that the manager has several years experience within care and the current organisation settings and had almost completed NVQ level 4. Staff spoken with confirmed that the manager is approachable and available to them for support as required. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 23 Information in the AQAA confirms that an annual questionnaire is circulated to both service users and staff and any identified actions are completed by the organisation. The action plan from 2008 was available and related to all of the organisations services and questionnaire responses, rather than just Mason Way. It identified who was responsible for taking the necessary actions and the timescales for completion. Monthly residents meetings are held in each of the houses to gather up-to-date views of the people using the service. There is a formal agenda that includes set items including health and safety, safeguarding and complaints. Records indicated that these issues are discussed with other areas added to the agenda by the tenants or staff such as menu ideas, developing the garden, events in the community and holidays as well as cleaning. A recent visit and report under regulation 26 by the Assistant Director of Operations looked at developing person centred planning at Mason Way, as well as complaints, accidents, staffing, service user meetings and communication. It also reviews issues from the last visit to ensure that actions are completed. The report confirms that quality monitoring is now available in house and that progress is monitored. Some residents manage their own money. One resident who was supported to manage their money requested this from staff and signed for its receipt. It was clearly explained to them that they now no longer had any personal allowance money left with the staff. Records kept of money returned to the person were available with supporting receipts and were safely stored. Aspects of health and safety at Mason Way were reviewed. One of the staff is a designated health and safety representative who attends the staff consultation group and feeds back to staff at team meetings. Current safety inspection certificates were available relating to the gas, electrical fixed wiring, portable appliances, emergency lighting and fire alarm. Records demonstrated that staff check the fire alarms, emergency lighting and hot water routinely and were recommended to take advice on checking cold water temperatures in relation to Legionella. A record of fire drills was maintained. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 24 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X 3 3 X Version 5.2 Page 25 138 to 138a Mason Way DS0000017721.V375994.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. Standard Regulation Requirement Timescale for action 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 YA19 Good Practice Recommendations Ensure that the furniture and carpets are clean and in good condition. 138 to 138a Mason Way DS0000017721.V375994.R01.S.doc Version 5.2 Page 26 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. 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