Care Home: 15 Thompson Drive

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What the care home does well Individual written needs assessments were in place before people were admitted to the home so that their diverse needs were identified and planned for. People were involved in valued and fulfilling activities and had their own hobbies and interests catered for. A visiting professional felt the service had improved over the last twelve months and stated that the health needs of the person they were involved with had been ‘properly’ addressed. Meals were healthy and nutritious and people said they ‘enjoyed’ their food. The communal areas of the home were well maintained and had good quality furnishings.15 Thompson DriveDS0000069784.V376710.R01.S.docVersion 5.2Staff were supported in their day to day work and there was a stable staff team that ensured consistency of care. Staff comments on a survey said they tried ‘to make Thompson Drive a proper home and not just a place where people live’ and tried to ‘give the residents a sense of belonging’. What has improved since the last inspection? The bathroom had been refurbished. Medication administration practice had improved and records were now being kept accurately. The way peoples’ worries and concerns were addressed had improved and there was now a mechanism for recording complaints and what action was taken to address them. Staff training had improved and mandatory health and safety courses had been held as well as a course on safeguarding vulnerable adults procedures. What the care home could do better: There must be secure storage for controlled drugs that meets recommended specifications. The service should obtain the most up to date copy of the Local Authority procedures on safeguarding adults. The service should provide its information, including the complaints procedure, in an ‘easy to read’ version so that people in the home can understand it. The policy on dealing with peoples’ finances should be reviewed and amended to state that staff should not be involved in making wills and being beneficiaries. 50% of care staff should achieve a National Vocational Qualification (NVQ) at level 2 in Care. There should be a statement about the persons’ health obtained before staff commence work at the service.15 Thompson DriveDS0000069784.V376710.R01.S.docVersion 5.2 Key inspection report CARE HOME ADULTS 18-65 15 Thompson Drive 15 Thompson Drive Codnor Derbyshire DE5 9RU Lead Inspector Janet Morrow Key Unannounced Inspection 22nd July 2009 10:30 15 Thompson Drive DS0000069784.V376710.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. 15 Thompson Drive DS0000069784.V376710.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 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 15 Thompson Drive Address 15 Thompson Drive Codnor Derbyshire DE5 9RU 01773 570163 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) M & A Dispensing Chemist Ltd Janet Wain Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider 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 category: Learning Disability - Code LD The maximum number of service users who can be accommodated is 3 2. Date of last inspection 14th August 2008 Brief Description of the Service: 15 Thomson Drive is a detached bungalow in a residential area in Codnor, close to local facilities and shops. All bedrooms are single rooms. The Home has a large lounge, dining room, kitchen and bathroom. Service users have access to a garden and seating area. The Home has a small staff team operating on a rota basis, providing one member of staff on duty at all times when service users are at the Home. Verbal information supplied in July 2009 stated that the weekly fees were £640.31. Copies of inspection reports can be provided by the manager of the home and are available on the Care Quality Commission’s website at www.cqc.org.uk 15 Thompson Drive DS0000069784.V376710.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. This inspection visit took place over one day for a total of 4.75 hours and concentrated on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection in August 2008. The manager was present during the inspection visit. One member of staff was spoken with and two people currently accommodated in the home were also spoken with. One visiting professional was spoken with by telephone following the inspection visit. Case tracking methodology was used; this means that the records of one person were examined in detail and feedback sought from relevant people to assess what impact the service had on the person’s health and well-being. Care records, a sample of policies and procedures and staff information were examined. A tour of the building took place. Three surveys were returned to the Care Quality Commission, two from staff and one from a person living in the home. What the service does well: Individual written needs assessments were in place before people were admitted to the home so that their diverse needs were identified and planned for. People were involved in valued and fulfilling activities and had their own hobbies and interests catered for. A visiting professional felt the service had improved over the last twelve months and stated that the health needs of the person they were involved with had been ‘properly’ addressed. Meals were healthy and nutritious and people said they ‘enjoyed’ their food. The communal areas of the home were well maintained and had good quality furnishings. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 6 Staff were supported in their day to day work and there was a stable staff team that ensured consistency of care. Staff comments on a survey said they tried ‘to make Thompson Drive a proper home and not just a place where people live’ and tried to ‘give the residents a sense of belonging’. What has improved since the last inspection? What they could do better: There must be secure storage for controlled drugs that meets recommended specifications. The service should obtain the most up to date copy of the Local Authority procedures on safeguarding adults. The service should provide its information, including the complaints procedure, in an ‘easy to read’ version so that people in the home can understand it. The policy on dealing with peoples’ finances should be reviewed and amended to state that staff should not be involved in making wills and being beneficiaries. 50 of care staff should achieve a National Vocational Qualification (NVQ) at level 2 in Care. There should be a statement about the persons’ health obtained before staff commence work at the service. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 7 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. 15 Thompson Drive DS0000069784.V376710.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 15 Thompson Drive DS0000069784.V376710.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): 2 and 3 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 was sufficient pre-admission information available to establish that the home was able to meet peoples’ needs. EVIDENCE: All the people living at the home had been admitted through the Local Authority care management system and assessment information was available from that process. The survey received from a person living in the home responded that they received enough information before deciding to move in. The written information supplied by the service stated that ‘a full assessment is given prior to admittance to the home to ensure that needs can be met’. One person’s care and support file was examined. This showed that there was information available from the assessment and care management system and 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 10 the service had also completed its own documentation. An individual care and support plan was in place based on an initial assessment of the person’s needs. 15 Thompson Drive DS0000069784.V376710.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): 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. Clear care planning and the promotion of independence ensured that people could make individual choices and manage any risks safely. EVIDENCE: The written information supplied by the service stated that it promoted ‘independence and risk taking, service users encouraged to make individual choices’. One person’s care file was examined and showed that a care plan was in place that demonstrated how individual needs would be met. These were detailed and informed staff how to manage any difficult behaviours as well as how to assist and encourage with daily activities, such as personal care and how to 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 12 communicate using a communication system. The manager stated that a multi-disciplinary review with the funding authority was booked for September 2009. Observation of people living in the home showed that they were able to make decisions and choices about their daily routines and spent their free time in activities of their own choosing. One person spoken with was able to say how they made choices and how they spent their day. The survey received from someone living in the home responded that they ‘sometimes’ made decisions about what to do each day. There were risk assessments in place in the file examined for key areas of support such as managing in the community with other people, managing the environment and challenging behaviour and these contained details on how to manage any risks safely. Staff spoken with were able to demonstrate that people were able to take risks within a risk management framework. The manager stated that no one currently had an advocate but she was aware of who to contact if necessary and had information on the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards. 15 Thompson Drive DS0000069784.V376710.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: 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 provided activities and opportunities that were age-appropriate and valued by people and promoted their independence. EVIDENCE: The written information supplied by the service stated that ‘Two service users attend the local day centre. One service user now remains at home and has one to one support throughout the week. One service user attends a local night class for computers. Service users are encouraged to use local amenities, pubs, shops, cinema, cafes’. Observation of one person during the inspection visit showed that they were able to communicate simply and make choices about how they spent their day. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 14 Photographs of a recent holiday were available that showed the person partaking in activities. The manager stated that a variety of activities were organised from the home including shopping trips, gardening and outdoor walks. One person spoken with had their own hobbies and interests and was able to speak about these and the pleasure they had from participating in special interest groups. The survey received from a person living in the home responded that they could do what they wanted each day, in the evenings and at weekends. Visiting hours were open and families and friends were able to visit when they wished. The manager was also able to give an example of one person refusing a family visit. Food stocks in the kitchen were at a good level and included fresh fruit and vegetables. There was evidence of peoples’ individual tastes being catered for. One person spoken with said they ‘enjoyed’ their food and observation of the evening meal showed that this was healthy and nutritious. The food budget was discussed with the manager and she stated that this was satisfactory and allowed her to purchase a variety of foods to suit individual tastes and for special occasions, such as birthdays. 15 Thompson Drive DS0000069784.V376710.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): 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. Peoples’ health and personal care needs were well managed, which ensured that good health was maintained. EVIDENCE: The written information supplied by the service stated that ‘all service users access local health professionals. All outcomes are recorded in personal files and Health Files’. One person’s health file was then examined and showed that all essential health information including weight monitoring and visits to General Practitioner (GP), optician etc were recorded. Medical appointments and outcomes were well recorded. One specific problem was being monitored on a monthly basis. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 16 Comments from a visiting professional confirmed that health needs were addressed; they said that the manager worked with specialist teams to address any concerns and that the health of the person they were involved with was stable and they were ‘happy with the progress’ made. During the inspection visit, it was observed that privacy and dignity was maintained; one person had their own key to their room and warm relationships between staff and people living in the service were apparent. Staff interactions were polite and courteous. Medicines were stored securely but the service did not have storage for controlled drugs that met recommended standards. This was raised as an issue at the previous inspection visit in August 2008. However, the service’s policy stated that controlled drugs were ‘to be kept in a locked cabinet with the specifications laid down in the Regulations’. The service was therefore not following its own policy. Failure to implement proper storage for controlled drugs may lead to action being taken by the Care Quality Commission to ensure compliance with this requirement. There were no controlled drugs in storage at the time of the inspection visit. All three medication administration record (MAR) charts were examined and showed that these were being completed accurately with amounts of medicine received recorded and codes being used properly, where applicable. One person’s medication administration record (MAR) chart was examined in more detail and showed that this was being completed accurately and it corresponded with the medicine administered. The manager undertook a weekly audit of the MAR charts to identify any inaccuracies. There were specimen staff signatures available and a photograph to aid identification of each person. A copy of the Royal Pharmaceutical Society Guidelines on ‘Handling Medicines in Social Care’ was available for reference. Staff spoken with confirmed that they had completed medication training in the past and that they were booked on to a refresher course in September 2009. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 17 15 Thompson Drive DS0000069784.V376710.R01.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. 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. Clear procedures ensured that peoples’ concerns were addressed objectively and that they were safeguarded. EVIDENCE: The content of the home’s complaints procedure was satisfactory and stated that complaints would be responded to within fourteen days. The written information supplied by the service stated that it ‘listened to service users’ and act on their views’ to try and resolve any issues. It also stated that no complaints had been received since the previous inspection visit in August 2008. There was a format for recording complaints but this had not been utilised as no complaints had been received. There had also been no complaints received at the office of the Care Quality Commission in the last twelve months. The survey from someone living in the home responded that they knew how to make a complaint and who to speak to if they were unhappy. One of the ways the service had identified it could improve in the next twelve months was by providing ‘a complaints procedure in a more understandable format’. It was currently only available in a written format. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 19 The service’s financial policy was examined and gave instructions on how peoples’ financial affairs should be dealt with. However, there was no information in the policy on dealing with peoples’ wills and being a beneficiary. One person’s financial records were examined. The cash held corresponded correctly with the record and was stored securely. Receipts for specific purchases were available. The person concerned had a solicitor dealing with their finances. The service had a policy on safeguarding adults and also had information from the Local Authority on reporting procedures available, although these were not the most up to date version. Staff spoken with were aware of their responsibility to report any suspicions of abuse and confirmed that safeguarding training was undertaken. Diary entries showed that this training was booked for August 2009. The service did not have any information on how to refer to the Protection of Vulnerable Adults (POVA) list. Both staff surveys received confirmed that staff knew what to do if anyone had concerns about the service. 15 Thompson Drive DS0000069784.V376710.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 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 premises were generally well maintained, which ensured that people had safe and comfortable accommodation. EVIDENCE: The written information supplied by the service stated that ‘The home has now been decorated throughout’. This was confirmed during the inspection visit as the communal areas of the home were well furnished, clean and tidy and the bathroom had been refurbished since the last inspection visit in August 2008. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 21 There was a pleasant garden area to the side of the building. The manager stated that a greenhouse was planned for the garden to enable one person to do more gardening. Two bedrooms were seen and were furnished according to individual needs and were personalised. One person used the key to their room independently. One person showed pride in their personal possessions and said they ‘liked’ their room. The laundry facilities were domestic and satisfactory and the home was found to be clean and hygienic, with no unpleasant odours. The survey received from a person living in the home responded that the premises were ‘always’ fresh and clean. 15 Thompson Drive DS0000069784.V376710.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 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. Training and recruitment practices were thorough, which ensured that staff had the skills to care for people. EVIDENCE: The staff rota for the week beginning 20th July 2009 was examined. This showed that there was one staff member on duty on each shift, with two being available twice weekly when two people were not out at day centres. There was one sleep in staff at night. Both the manager and staff members spoken with felt there were enough staff available to provide the care required. Both staff surveys received responded that there were ‘usually’ enough staff to meet individual needs. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 23 The written information supplied by the service stated that one of the five staff members at the service had achieved a National Vocational Qualification at level 2 or above. One person was undertaking a level 3 qualification. This meant that the home was not yet meeting the target of having 50 of staff qualified to NVQ level 2 or above. Staff training information examined showed that mandatory health and safety training was undertaken as well as other training in relation to the needs of the people living at the home. Training certificates showed that courses undertaken since the last inspection in August 2008 included the Mental Capacity Act and one staff member spoken with confirmed that they were due to undertake training on safeguarding vulnerable adults. The manager stated that courses being arranged in the next few months included dealing with challenging behaviour, medication and health and safety. Both staff surveys received responded that relevant training was provided. One staff file was examined for recruitment records. This showed that a thorough recruitment process was operated and that most of the information required by Schedule 2 of the Care Homes Regulations 2001 was in place, including evidence of Criminal Record Bureau (CRB) checks, identity information and two written references. However, there was no statement regarding health and fitness in the application information. Both staff surveys received confirmed that recruitment checks took place before employment began. 15 Thompson Drive DS0000069784.V376710.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well run in the best interests of people living there. EVIDENCE: The manager was registered with the Care Quality Commission. The written information supplied by the service stated that ‘Support given to staff on a regular basis.’ This was confirmed by those staff spoken with. They described the running of the home as ‘stable’ and described the manager as ‘spot on’. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 25 Both staff surveys received responded that they met ‘regularly’ with the manager to discuss work and get support. The written information supplied by the service stated that ‘Surveys sent out twice yearly to families and other health professionals. Staff surveys done twice yearly.’ Examination of quality assurance processes confirmed this and the most recent surveys had been undertaken in June 2009. Most areas surveyed received responses of ‘very good’. Comments received from visiting professionals stated that there had been a ‘significant improvement in communication’ and that staff were ‘very helpful’. The owners were undertaking monthly audits, as required by Regulation 26 of the Care Homes Regulations 2001, and records of these visits showed how they intended to improve. Meetings with people living in the home were also held and notes from these were seen from April 2009. The manager also stated that staff meetings were held every three or four months. Staff spoken confirmed that health and safety training was undertaken in food hygiene, first aid, moving and handling and fire safety and this was confirmed on training records seen, which stated that this training had occurred between November 2008 and February 2009. The written information supplied by the service stated that maintenance checks were undertaken regularly; records seen in the service confirmed that portable electrical appliances had been tested in March 2009, fire fighting equipment had been checked in May 2009 and gas safety in October 2008. 15 Thompson Drive DS0000069784.V376710.R01.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 X 2 3 3 3 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 X 26 3 27 X 28 X 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 2 X 3 X 3 X X 3 X Version 5.2 Page 27 15 Thompson Drive DS0000069784.V376710.R01.S.doc YES 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 A secure facility must be provided to recommended specifications to ensure the safe storage of controlled drugs. Previous timescale of 30/11/08 not met; timescale extended to 30/09/09. Timescale for action 30/09/09 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 YA22 Good Practice Recommendations The service should be working towards providing all documents, to which service users should have access, in an ‘easy read’ format. This should include the complaints procedure. The policy on dealing with peoples’ finances should be reviewed and amended to state that staff should not be involved in making wills and being beneficiaries. DS0000069784.V376710.R01.S.doc Version 5.2 Page 28 2. YA23 15 Thompson Drive 3. 4. 5. YA23 YA32 YA34 The service should obtain a copy of the most up to date Local Authority safeguarding procedures. 50 of care staff should achieve a National Vocational Qualification (NVQ) at level 2 in Care. There should be a statement about the persons’ health obtained before staff commence work at the service. 15 Thompson Drive DS0000069784.V376710.R01.S.doc Version 5.2 Page 29 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. 15 Thompson Drive DS0000069784.V376710.R01.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. 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