Care Home: 17 Gordon Road

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What the care home does well Residents at Gordon Road receive very individual care and it was evident during the inspection that the staff are there for the residents and the service they receive enhances their lives. Feed back from both the staff and residents was very positive and there was a homely atmosphere. Care was provided with dignity and respect and residents were involved in the day to day running of the home. Staff incorporated the residents into conversations about general issues and there was a real family feeling. There is a very open atmosphere in the home and the staff were very positive about the Manager and stated she was approachable and offered advice and support when needed. What has improved since the last inspection? Gordon Road has a new Manager in place since the last inspection. She is presently looking at the systems and paperwork in place to ensue it meets the National Minimum Standards. New systems have been introduced and resident and staff files were easy to read and contained all the required information. Outcomes for the residents at the home are very good. The Manager is looking to produce much of the present written information for the residents in pictorial form; so are able to have a better understanding. Some decoration has been completed around the home, including the residents` bedrooms. The home is clean and tidy and provides a good homely feeling for residents and relatives. What the care home could do better: Generally the care provided at the home is good and systems are now in place to evidence this. Gordon Road only had one requirement at the last inspection and this was around recruitment practice and induction. Evidence seen during this inspection that confirmed that these areas had been developed and the information required was now present. No requirements have been made from this inspection. Key inspection report CARE HOME ADULTS 18-65 17 Gordon Road 17 Gordon Road Vange Basildon Essex SS14 1PN Lead Inspector Mrs Sharon Lacey Key Unannounced Inspection 24th & 25th June 2009 09:30 17 Gordon Road DS0000018111.V376256.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. 17 Gordon Road DS0000018111.V376256.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 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17 Gordon Road Address 17 Gordon Road Vange Basildon Essex SS14 1PN 01268 282777 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) teresa.rudd@familymosaic.co.uk www.familymosaic.co.uk Family Mosaic Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 3 19th July 2007 Date of last inspection Brief Description of the Service: 17 Gordon Road provides care and accommodation for three adults with a learning disability. The home’s facilities include a comfortable open plan living room, dining room and kitchen. There is also a shower room, an office and a laundry room on the ground floor. Upstairs there is a bathroom, three bedrooms for residents and a sleeping in room for staff. Gordon Road has a reasonable sized and secluded garden to the rear of the house, which all residents can access. The home is situated within walking distance of local shops. Basildon town centre is a short distance away. There is a good bus service in the area. Residents within the home are encouraged to access leisure pursuits and community facilities and are supported by experienced staff. The home has its own transport available. A Statement of Purpose and Service Users Guide about the home were available. 17 Gordon Road DS0000018111.V376256.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 two stars. This means that people who use this service experience good quality outcomes. This was a routine unannounced inspection, which took place over eight hours. It was a Key Inspection covering all 43 of the National Minimum Standards. A tour of the home and an inspection of the environment were completed and records and documentation viewed. Areas looked at included information given to residents about the home and its services before being admitted, information gained by the home from residents when they first come into the home, how this information is then given to staff on the care required, the facilities and environment of the home, and any complaints that may have been received since the last inspection. Also the staffing and management of the home were inspected. An Annual Quality Assurance Assessment (AQAA) was sent to us by the Manager. The AQAA is a self-assessment which focuses on how well they consider they are meeting the outcomes of the people using the service. It also provides statistical information about the service and how the service intends to improve over the next 12 months. Information from this document has been used in this report where appropriate. All residents at Gordon Road were spoken with during the inspection and information also gathered from residents through observation and interaction with the staff. Questionnaires were sent out to the home to be distributed between the residents, but these were not returned by the required date so feedback has not been able to be sought from staff or residents. All staff members on duty were spoken with informally during the inspection and any feedback has been included as part of the report At the end of the day the inspection was discussed with the Manager and advice and guidance was given regarding the findings. There is an easy read summary of this report available. 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 6 What the service does well: 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. 17 Gordon Road DS0000018111.V376256.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 17 Gordon Road DS0000018111.V376256.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): 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. Users of the service can be assured they will receive the care they require and that there will be an assessment to clearly identify their care needs. EVIDENCE: The Statement of Purpose and Service User Guide were reviewed. Both documents had recently been updated and were well presented and provided good information on the services Gordon Road offered. The Manager advised that she is presently looking to do the Statement of Purpose and Service User Guide in pictorial form, for those residents who have communication difficulties. Both documents are kept in the Managers office, but it was recommended that copies were also placed on the notice board, so relatives and residents can gain access to this information if required. The AQAA stated that there had not been any new admissions to the home and that the current residents had been living at Gordon Road for over 20 years. The Manager confirmed that an assessment would be completed on any new admissions and that information would be gained from the individual, family and other professionals. A copy of the assessment form and referral form was provided and these included details of the next of kin, goals and aspirations, 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 9 wellbeing, enjoying and achieving, being healthy, staying safe, positive contribution, healthcare needs, physical and emotional needs, education and leisure and relationships. The Manager confirmed that any new residents would be invited to visit the home for a trial period. Residents are provided with a contract and those files viewed contained a pictorial tenancy agreement. The Manager stated that she wanted to develop these further to be more individual to each resident. There is advocacy group and support is available to residents if needed. It was confirmed that one present resident has their own Advocate. A copy of the homes last inspection report and registration certificate was made available. 17 Gordon Road DS0000018111.V376256.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): 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. Users of the service can be confident they will be support and consulted with on how the home is run. EVIDENCE: Resident files viewed contained a plan of care, which consisted of a set form that provided details of the residents needs and how these were to be met. The plan of care set out the aspirations and goals for each resident and included choice where possible. When speaking to the Manager she confirmed that the plans would be arranged with the resident and also their families. Families would be involved in reviews and decisions on how care was to be provided and files viewed contained evidence of this. Staff spoken to during the Inspection were very knowledgeable of the residents needs and abilities and were observed trying to encourage independence and choice as much as possible 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 11 The residents were viewed being encouraged to make decisions about their life and staff were seen to assist and support them where this was needed. During the inspection staff were seen to offer the residents choice. This was in the form of drinks available, a variety of foods for tea and lunch and they were encouraged to assist with daily household tasks, such as taking the clothes in from the washing line and taking them up to their room. One resident expressed they did not wish to do this and the staff were observed not to pressure them but encouraged them take part. There was regular communication between staff and they incorporated the residents in any conversations and spoke about what each individual resident had done during the day and encouraged residents to respond. Staff were observed communicating verbally and via sign language with the residents and encouraging intervention. Residents were observed in being involved in the day-to-day running of the home. House meetings and residence meetings take place regularly. On viewing the minutes of the meetings these contained documentation that residents had been involved in discussions about how the home was running and around food etc. The Manager confirmed that there is also a User Satisfaction Survey which is done to gain views from residents and relatives about the care being provided. One aim for improvement over the next 12 months was with regard to improving house meetings. They are aiming to hold these at a level the residents understand and in a format relevant to the individual; using pictures and Makaton where appropriate. In discussion with the Manager she was aware of her responsibilities regarding risk assessments and was able to provide examples on where these have been done with residents due to their care needs changing. There is a set risk assessment form and files viewed contained copies of these documents. Staff were observed supporting residents in daily life skills to help enhance their independence. The home has a policy on confidentiality and staff are provided with written guidance during their staff induction. The Manager confirmed that the home is registered under the Data Protection Act. Service users files are kept in lockable cabinets. 17 Gordon Road DS0000018111.V376256.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: 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. Users of the service can be assured that activities will be provided to enhance their leisure and educational opportunities. They will be offered choice in food and their dietary needs will be met. EVIDENCE: From viewing documentation and through observation in the home it was clear that the residents of Gordon Road are given opportunities for personal development and to maintain social and community links. Residents attend different activities during the day and also during the evenings. They each have a weekly diary, which contains details of different activities that will occur each week. On the day of inspection one resident was taken out by their advocate to visit the local sea side. Staff also assisted another resident to attend a local college. Gordon Road has its own transport, which helps the residents to gain access to the community and other outings. 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 13 It was confirmed that the residents are assisted to take part in leisure activities in the local community. Visits to the local pubs, shops, markets, libraries, cinemas and theatres have all been arranged. One staff member advised that the gardening tasks were completed with one of the residents and as they had enjoyed this so much, they had arranged for the resident to do a gardening course at the local college. It was explained by staff and residents that there had been a recent outing to Clacton and the residents expressed they had enjoyed this. Arrangements had been made to ensure that all the residents were going on holiday and they had been involved in the organisation. There was much excitement as they were due to go away the week after the inspection took place. The AQAA advised that visits to relatives and friends are arranged. It was confirmed that residents at Gordon Road socialise with other residents at one of their other care homes and supported to maintain family links. There was also a relaxed feeling within the home and the staff and residents were seen to have a good relationship. Residents are encouraged to open their own posts, but staff will assist in reading this and explaining the content if required. Evidence of this was seen during the Inspection when one staff member asked the residents if they would like to go to another room so they could explain the content of the letter. A menu has been produced for the home taking into consideration the residents likes and dislikes. The menu seen offered variety and had been organised around any dietary needs of each resident. Staff were observed offering residents choice for their evening meal and lunchtime. On the evening of the inspection residents chose to visit the local fish and chip shop for their tea and on the second day of the inspection residents chose omelette, with crisps, juice and tea and cheese sandwiches on either brown or white bread. Tea and biscuits were provided during the day, plus snacks of fruit and crisps. Residents spoken to were complementary about the food. 17 Gordon Road DS0000018111.V376256.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): 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. Users of the service can expect to receive personal support in the way they prefer and have their physical and emotional care needs monitored and met. The procedures for medication will assist in keeping them safe. EVIDENCE: The AQAA stated that support plans for personal care and healthcare are written with the consultation of the residents. It continued that medical needs were met by GPs and other professionals. Residents files showed that their healthcare needs had been monitored and that they had access to community health facilities. Care plans contained information on hospital visits, GP visits and dental visits etc. It was confirmed that there is no district nurse needed at home at present. During the inspection residents were observed being provided with personal support, which respected their privacy, dignity and independence. Staff confirmed that the routines in the home were very flexible and residents were enabled to get up and go to bed when they wanted. Advocacy services are also available to help residents with individual choices and independence. 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 15 The residents had also been involved in choosing the colour of their bedrooms when they were recently decorated. Written evidence was available that the residents received personal support in a way they preferred and their individual care plans included residents’ preferences where possible. Gordon Road has a Key Worker system, which enables the staff member to get to know the individual resident and provide care in the most appropriate way. Whilst observing staff it was very clear that they were all aware of each individual residents care needs and also their likes and dislikes, which aided continuity of care. Gordon Road has a medication policy and procedure. None of the present residents are able to administer their own medication and rely upon staff to assist in this process. During a tour of the home the medication was checked and storage was good and all residents had photos to assist in identification. There was a list of signatures to show which staff could assist with medication. Of the records sampled these were well maintained with no anomalies seen. It was noted that bottles of medication that had been opened did not always have a dated on when this occurred. It was confirmed that staff had been provided with medication training by Boots Chemists. It was confirmed that Gordon Road is a home for life and the residents would be assisted to stay there for as long as possible. The Manager explained that they had been looking to get the assistance of an occupational therapist to help assess one resident whose mobility had become reduced. Due to the only access to the first floor being by stairs, it had already been recognised this may be a problem if any of the present residents were unable to continue to use these. 17 Gordon Road DS0000018111.V376256.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): 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. Residents and their families can be confident that their complaints will be listened to and appropriate action taken. People who use the service can be confident that the policies and procedures in place will assist in their protection against abuse, neglect and self harm. EVIDENCE: The AQAA states there is a robust policy in place on how complaints are dealt with, including a timescale that must be adhered to. It adds that staff are aware of the procedure and will assist at every stage. The complaints procedure is available to all residents and their families and details could be found in the Service Users Guide and Statement of Purpose. The Manager had a complaints folder and when looking through the information it was apparent that the last complaint the home had received was in April 2008. This had been investigated and appropriate action taken. Policy and procedures were available on Whistle Blowing and Safeguarding Adults. There was also pictorial safeguarding information on the board outside of the office to advise the residents of the process. All staff had attended safeguarding training. 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 17 There are clear policy and procedures regarding residents’ monies and financial affairs. The home has systems in place for residents monies. It was confirmed that regular audits are completed and staff were observed dealing with residents finances appropriately during the inspection. Two residents finances were checked and these were in order. 17 Gordon Road DS0000018111.V376256.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): 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. Residents can expect to live in a homely, comfortable and safe environment, which meets their individual needs. EVIDENCE: Gordon Road is suitable for its stated purpose and offers residents a homely, comfortable and safe environment. The furnishing at the home is of a good quality and the home is well laid out for residents use. The accommodation would not be suitable for wheelchair users or those with restricted mobility. Each resident has their own bedroom, which had recently been decorated to a colour of their choice. Each bedroom contained personal belongings and photographs, which helped individualise and make it a personal space. None of the bedrooms had ensuite facilities, but there was access to a hand wash basin. 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 19 There was good, communal space within the home, which consisted of a lounge and a separate dining room. There is also a large separate kitchen, which had all modern facilities. There were utility facilities, which had laundry, drying, storage and the use of a sink. The garden had a patio with tables and chairs and residents were viewed using this during the inspection. The bathing facilities within the home were sufficient and consisted of a bath or shower. The toilets and bathrooms were lockable, to ensure residents privacy and dignity was upheld. Gordon Road offers a safe and well maintained environment, which is clean and free from odours. The Manager stated that she had recently attended an infection control course and it was now her responsibility to cascade this down to the staff. 17 Gordon Road DS0000018111.V376256.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): 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. Residents can be confident that they will receive care from a skilled, experienced and supervised workforce. Residents are supported and protected by the homes recruitment policy and practices. EVIDENCE: The Manager confirmed that recruitment is still done centrally at head office. The files of two staff members that had been recruited since the last inspection were viewed. These contained all the relevant checks and confirmed the recruitment policy had been followed. The Manager stated she was in the process of sorting out the staff files. She provided evidence of one that she had recently completed. This was found to be easy to read, had been divided and contained details of supervision, job description, training, personal information, and recruitment. 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 21 When viewing staff files these contained a job description advising them of their role and who theyre responsible to. The Manager confirmed that staff do not at present receive copies of the General Social Care Council Code of Conduct. The Manager confirmed that all new staff are provided with an induction, which is in line with the Skills for Care modules. It was confirmed that this consisted of a week course and is completed by all new staff. On discussing this with the staff on duty they confirmed they had received an induction and the staff files viewed contained documentation to confirm this. The Manager confirmed that training is done in-house. The Manager provided a copy of a matrix showing staff training. From this it was confirmed that staff had attended training in moving and handling, fire safety, first aid at work, food safety, health and safety, epilepsy, mental capacity act, safeguarding and medication. From the documentation seen staff had the skills and experience necessary for the care tasks they are expected to do. With regard to staff that had completed NVQ training it was established that three staff had completed their NVQ 2. This means that the home has achieved the recommendation that 50 of their care staff achieves NVQ 2. The Manager is hoping to do her NVQ 4 in Management and Care. Staff rotas viewed contained details of the staff member, their job title and the shift to be completed. There was also a pictorial staffing rota on the wall outside of the office so that residents were away of the identity of the staff member and their role within the home. The Statement of Purpose provided information on the shift patterns within the home. It was confirmed that there are always two members of staff on duty from 7.00 am to 22.00 pm and one sleep person who is on call during the night. The Manager advised she tries to use bank staff to assist with continuity of care for the residents. It was confirmed by the Manager that supervision consists of one to ones, yearly appraisals, management appraisal and self appraisals. It is the Managers responsibility to supervise all staff and it was confirmed that she also receives support from upper management. Gordon Road is a small home and staff were observed gaining support and advice from the Manager during the inspection. Supervision documentation was available on the files inspected. 17 Gordon Road DS0000018111.V376256.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): 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. Residents can be confident that the home is run by person who has the necessary experience and skills. Residents and relatives can expect to be approached to gain their views about the running of the home and the care provided. EVIDENCE: The Manager has only been employed at the home for the last two months. On speaking with staff they were very positive about the new Manager and stated she was very approachable and supportive. It was clear from the training records that she had the experience and knowledge to run the home. She has applied for to do her NVQ 4 in Management and Care and is aware of her responsibilities with regard to running the home. 17 Gordon Road DS0000018111.V376256.R01.S.doc Version 5.2 Page 23 The Manager advised that she receives regular support in the running of the home and is able to gain advice if and when required. During the inspection she showed a good knowledge of the standards and regulations and had been implementing systems to assist her in providing written evidence to meet the National Minimum Standards. The Statement of Purpose and Service Users Guide contained details of the homes aims and objectives and their philosophy of care. As previously stated there was a good atmosphere in the home and it was clear that the staff were there for the residents and they wanted to improve their quality of life. Staff spoken with during the inspection had no concerns about the management or running of the home. It was confirmed that there were systems in place to gain the views of the residents and relatives about the care provided and the running of the home. The AQAA stated that a yearly satisfaction survey in the form of a questionnaire is sent to residents and relatives and a report produced from the findings. A copy of the last quality audit completed in the home (April 2009) was made available. Relative and residents meetings are organised on a four weekly basis and clear evidence of these were available. There are also systems in place for management to visit the home and complete certain checks and audits each month. The Manager was aware of her responsibilities regarding the health and safety of both staff and residents. Evidence was gained that regular checks had occurred on fire alarms, risk assessments, hot water checks, gas safety, emergency lighting, and PAT testing. The accident book was seen and this had been well completed. The last accident was in connection to a fall that a resident had had on the 22nd April 09. The home has policies and procedures in place, but these were not fully viewed during this inspection. The Manager advised that staff are provided with written guidance and copies of the policies and procedures when they first start working for the company. Some policies and procedures had been produced in picture formats, to enable the residents to read them. There was also evidence of a discussion on the policies and procedures as recent staff meeting. It was confirmed that residents can have access to their files and records. The Manager stated that she is in the process of tidying up the present records and trying to put them in a more organised system. There are individual records for both service users and staff and the Manager confirmed that they are registered with the Data Protection Act. 17 Gordon Road DS0000018111.V376256.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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Version 5.2 Page 25 17 Gordon Road DS0000018111.V376256.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 YA1 Good Practice Recommendations It is recommended that a copy of the Service User Guide and Statement of Purpose is made available to residents and visitors to the home. It is recommended a review date is placed on the Service User Guide and Statement of Purpose to help identify when these documents have been reviewed and updated. It is recommended that staff date bottles and boxes of medicines when they have been opened to assist in the audit trail and to ensure they are used within the recommended dates. It is recommended that a safer system is introduced to store disposable gloves, due to the health and safety risk to residents. It is recommended that staff are provided with copies of the General Social Care Councils Code of Practice when the are first employed. DS0000018111.V376256.R01.S.doc Version 5.2 Page 26 2. YA1 3. YA20 4. YA30 5. YA31 17 Gordon Road Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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