Care Home: 23 Cecil Road

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What the care home does well The environment was comfortable and well maintained. Staff were well supported and had clear guidelines and instructions on how to meet the needs of people living in the home and had access to a good training programme. One staff survey said ‘the manager and deputy manager give excellent support to the staff team and service users’. Peoples’ care and support records were clear, comprehensive and personalised. There were a range of age appropriate activities for people living in the home and independence and decision-making was well managed. People said they ‘liked’ living there. A relative’s survey said ‘although there are areas which 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 need improvement, this service is the best I have experienced for my son’s needs’. What has improved since the last inspection? The manager had become registered with the Care Quality Commission (previously the Commission for Social Care Inspection). Care and support records had been improved to ensure that all risks associated with health, safety and well being had been addressed. Medication procedures had been improved to ensure that medication administration record (MAR) charts were completed accurately and appropriate pharmaceutical guidance had been obtained for reference. Complaints were being properly addressed and fully documented. Additional training had been provided to ensure staff were able to deal with mental health needs. Redecoration had occurred and people had chosen their own colour and design schemes for their bedrooms. What the care home could do better: Staffing levels should be reviewed to ensure that peoples’ chosen activities can always be carried out as planned. There should be 50% of staff with a National Vocational Qualification at level 2. Key inspection report CARE HOME ADULTS 18-65 23 Cecil Road Dronfield South Yorkshire S18 2GW Lead Inspector Janet Morrow Key Unannounced Inspection 6th July 2009 09:00 23 Cecil Road DS0000067816.V376414.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. 23 Cecil Road DS0000067816.V376414.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 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23 Cecil Road Address Dronfield South Yorkshire S18 2GW 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) 01246 291673 01246 291901 londonroad@tiscali.co.uk Milbury Care Services Ltd Alison Mahoney Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 6 27th August 2008 Date of last inspection Brief Description of the Service: The home is a converted building situated in the village of Dronfield, which is on the boundary of Derbyshire and South Yorkshire. It consists of a lounge, dining room, kitchen, activity rooms and office on the ground floor, with bedrooms and bathrooms on the 1st and 2nd floors. The home does not have a lift facility. The fees for the home are not set at a minimum or maximum, but each individual service user has a contract with specific costs to meet their assessed needs. 23 Cecil Road DS0000067816.V376414.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 5.25 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 throughout the inspection visit. Two members of staff were spoken with and two people currently accommodated were also spoken with. One visiting professional was spoken with by telephone after 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. Nine surveys were returned to the Care Quality Commission shortly after the inspection visit; two from people living at the home, four from staff, one from a visiting professional and two from relatives. Care records, a sample of policies and procedures and staff information were examined. A partial tour of the building took place. Written information in the form of an annual quality assurance assessment was provided by the service prior to the inspection visit and this informed the inspection process. What the service does well: The environment was comfortable and well maintained. Staff were well supported and had clear guidelines and instructions on how to meet the needs of people living in the home and had access to a good training programme. One staff survey said ‘the manager and deputy manager give excellent support to the staff team and service users’. Peoples’ care and support records were clear, comprehensive and personalised. There were a range of age appropriate activities for people living in the home and independence and decision-making was well managed. People said they ‘liked’ living there. A relative’s survey said ‘although there are areas which 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 6 need improvement, this service is the best I have experienced for my son’s needs’. 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. 23 Cecil Road DS0000067816.V376414.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 23 Cecil Road DS0000067816.V376414.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): 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 admission information available to establish that the service was able to meet individual needs. EVIDENCE: The written information supplied by the service stated that ‘a pre-admission holistic assessment is carried out to ensure we are able to meet the needs of the potential service user.’ One person’s care and support file was examined. This showed that there was information available from the assessment and care management system and 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. The survey received from a visiting professional responded that the service’s assessment arrangements ‘usually’ ensured that accurate information was gathered. 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 9 There were risk assessments in place that took into account individual needs and indicated risks that people chose to take and how they were managed safely. Both surveys received from people living in the home responded that they received enough information before deciding to move in and both relatives’ surveys responded that they ‘usually’ received enough information to help make decisions. 23 Cecil Road DS0000067816.V376414.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. There were comprehensive care and support plans and risk assessments, which ensured that people were able to make safe decisions and maintain independence. EVIDENCE: The written information supplied by the home stated that ‘We provide individual plans based on the assessment of need’ and ‘Service users are supported to make informed decisions/choices in all aspects of their lives.’ One person’s care records were examined and showed that a comprehensive care plan was in place, with a specific one covering decision-making. There were also other key areas covered such as managing finances, behaviour, 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 11 mobility, social, mental and physical interventions. The care plan was in sufficient detail to instruct staff how to encourage and maintain independence and it was up to date and reviewed at regular intervals. It was personalised and written from the point of view of the person and included clear instructions on how support was best given. For example, it stated that to ‘show pictures’ helped the person make appropriate choices. There were risk assessments in place for each area of support 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. Discussion with 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. Both surveys received from people living at the home responded that staff ‘usually’ listened and acted on what was said. Observation during the inspection visit showed that people were offered choices and also made their own decisions about what to do in the day. One person spoken with confirmed that they had decided how to decorate their room. 23 Cecil Road DS0000067816.V376414.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. The service helped to arrange activities and services that were age-appropriate and valued by people, which promoted their independence. EVIDENCE: Those people spoken with confirmed that they were able to have their own routines and have visitors or go out into the community when they wished. This was directly observed during the inspection visit. Activity plans for each person were available and showed a range of activities on offer. In discussion, one person stated that they went to college and another went out shopping and had his own interests within the home. 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 13 The written information provided by the service stated that people were enabled ‘to experience a wide range of leisure activities’ and were encouraged and supported in the continuation and development of existing activities. It also stated that the service facilitated ‘attendance to external learning establishments’ and this was confirmed in discussion by one member of staff. One person living in the home was in employment. Both surveys received from people living in the home responded that there were ‘always’ activities arranged that they could take part in. However, one also commented that an improvement would be ‘to go out more with their family’ and a relatives’ survey commented that ‘frequently activities are curtailed due to insufficient staff’. Visiting hours were open and families were able to visit when they wished and one person was visiting family at the time of the inspection visit. The care and support record examined showed that the person concerned was supported to maintain contact with their family. Meal times were flexible, which enabled people to plan activities at times of their choosing. Food stocks in the kitchen were at a good level and had a range of fresh and frozen food. Both surveys received from people living in the home responded that they ‘always’ enjoyed their meals. The written information supplied by the service stated that ‘well balanced and varied choice of meals is available based on individual preferences’. Examination of menus confirmed that meals were varied, wholesome and nutritious. People living in the home were able to assist in food preparation if they wished. They were also involved in food shopping. 23 Cecil Road DS0000067816.V376414.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. Peoples’ health and personal care needs were well managed, which ensured that good health was maintained. EVIDENCE: The service had flexible routines based on peoples’ assessed needs, stated preferences and activities being undertaken. In discussion, staff had good knowledge of peoples’ individual preferences and interests. The written information supplied by the service stated that ‘Service users have an individual “health folder” to ensure information in each area is recorded accurately and in chronological order to ensure ease of access’. One person’s health file ws examined and showed that all essential health information including weight monitoring and visits to General Practitioner (GP), optician etc 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 15 were recorded. The health file examined showed that there was also information available from external professionals and that reviews of care took place that covered a wide range of needs and involved relevant health professionals. Both surveys received from people living at the home responded that they ‘always’ received the medical care needed, one relatives’ survey received responded that the support needed was ‘usually’ given and the other responded that it ‘always’ was. The survey from a visiting professional responded that the service ‘usually’ sought advice to improve health and well being and commented that it ‘asked for advice if required’. During the inspection visit, it was observed that privacy and dignity was maintained by people having the keys to their own rooms and staff interactions were polite and courteous. There was an agreement displayed on the wall signed by all people living in the home that said what acceptable behaviours were; for example, ‘no swearing’. All four 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 chart was then examined in more detail and was accurate and corresponded with the medicine administered. A copy of the Royal Pharmaceutical Society Guidelines on ‘Handling Medicines in Social Care’ was available. There was secure storage available for controlled drugs. There were no controlled drugs in storage at the time of the inspection, although one medicine was being stored under controlled conditions. One person was being supported to learn how to manage their own medication and was countersigning the MAR chart. The written information supplied by the service stated that ‘all staff that administer medication have been appropriately trained to do so’. They had also had their competence assessed to administer medication. This was confirmed by staff in discussion and by documentation on staff files. 23 Cecil Road DS0000067816.V376414.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. Clear procedures ensured that peoples’ concerns were addressed objectively and that they were safeguarded. EVIDENCE: The written information supplied by the service stated that there had been three complaints received at the home since the last inspection visit in August 2008. There had been no complaints received at the office of the Care Quality Commission (previously the Commission for Social Care Inspection). The complaints record was examined and showed that all three complaints received had been dealt with properly and the complainant was satisfied with the outcome. There was a comments book where people living in the home and visitors could write in concerns and compliments. A concern had been made in this book by someone living in the home and it had been addressed properly. Both surveys from people living in the home responded that they knew how to make a formal complaint, as did both relatives’ surveys received. One relatives’ survey responded that the service ‘usually’ responded appropriately to any concerns raised and the other responded that it ‘always’ did. 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 17 The financial record of one person’s personal allowance was examined. The cash held corresponded correctly with the record and was stored securely. Two people were signing the record to verify the transactions. Receipts for purchases were available. Financial procedures ensured that cash held was checked on each shift. The service had a policy on safeguarding adults and also had up to date information from the Local Authority on reporting procedures. The written information supplied by the service stated that knowledge of this policy was included in the induction process. Both members of staff spoken with confirmed this and were aware of their responsibility to report any suspicions of abuse and confirmed that safeguarding training was undertaken. Training records showed that this training had occurred in January 2009. All four staff surveys received responded that they knew what to do if anyone expressed concerns about the service. 23 Cecil Road DS0000067816.V376414.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. The home was well maintained, which ensured that people had safe and comfortable accommodation to live in. EVIDENCE: The home was clean, well decorated and odour free. There was one lounge and one dining room plus a small activity area and a sensory space for people to utilise. There was also a pleasant lawned area to the rear of the home with garden furniture. The written information supplied by the home stated that bedrooms were furnished according to individual needs and were personalised. This was confirmed by one person spoken with but no-one asked gave permission for 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 19 their rooms to be viewed. Those people able to do so had the key to their rooms. Both surveys received from people living in the home responded that the premises were ‘always’ fresh and clean. The laundry facilities were domestic in nature and satisfactory. There was secure storage for cleaning materials and comprehensive product information to comply with Control of Substances Hazardous to Health (COSHH) regulations. Staff spoken with knew how to control the spread of infection and confirmed that there were plenty of gloves and aprons available for use. 23 Cecil Road DS0000067816.V376414.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, 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 6th July 2009 was examined. This showed that two staff were on duty in the mornings and afternoons whilst one person living in the home was away and three when all people in the home were present. There was one waking and one sleep in staff at night. The manager was supernumerary for three days per week. Both the manager and staff members spoken with felt there were enough staff available to provide the care required and confirmed that agency staff were used to cover any absences. 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 21 Three of the four staff surveys received responded that there were ‘always’ enough staff available and one responded that there ‘usually’ were. However, one relatives’ survey commented that ‘better staffing levels’ was an area that could be improved and that there was a ‘rapid turnover of staff’. The survey from a visiting professional also commented that ‘there have been concerns in the past with high turnover of staff’ but went on to say that ‘at present there appears to be a stable team’. The written information supplied by the service commented that it was difficult to recruit staff; this was discussed with the manager who stated that a recent recruitment drive had been successful and a good response of potentially suitable candidates had been received. Staff training information examined in the home 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 mental health awareness, epilepsy and the Mental Capacity Act. Staff spoken with confirmed that access to training was good and three of the four staff surveys received confirmed that they were given training relevant to their role. One staff survey did not give a response. One survey commented that there were ‘good training and promotion prospects’. The written information supplied by the service stated that three of ten care workers had achieved a National Vocational Qualification (NVQ) at level 2. This meant that the home was not yet achieving the target of having 50 of staff with an NVQ2. Training records showed that this training was undertaken. Three staff recruitment records were examined. These showed that a thorough recruitment process was operated. Although some of the original documentation was located at the company’s head office, there was a checklist signed to say that the information required by Schedule 2 of the Care Homes Regulations 2001 was in place, including evidence of Criminal Record Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) First checks, identity information and two written references. 23 Cecil Road DS0000067816.V376414.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 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 service was well managed and run in the best interests of people living there. EVIDENCE: The manager had become registered with the Care Quality Commission (previously the Commission for Social Care Inspection). She had achieved the Registered Managers Award and a National Vocational Qualification to level 4 in care. She was able to demonstrate her competence throughout the inspection by her knowledge of the service users, the service, and policies and 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 23 procedures. A comment seen in the comments book from one of the people living in the home stated that she was ‘a very good manager’. All four staff surveys received responded that the manager ‘regularly’ gave enough support and one commented that there were ‘regular staff meetings, service user meetings and information is passed down effectively through the team’. The company had clear processes for quality assurance and completed an annual service review when they tried to obtain views and comments from a range of different people, including visiting professionals and relatives. Monthly audits were undertaken. An action plan was then devised and followed up on the following month. This was in addition to the usual monthly visits undertaken in response to Regulation 26 of Care Homes Regulations 2001. The analysis of the review undertaken in September 2008 was examined and showed that there were good levels of satisfaction within the home. Care reviews were also used as a mechanism for obtaining feedback and one review had comments recorded that stated the person was ‘very pleased’ and that staff had a ‘more consistent approach’, which had been of benefit to the person concerned. Staff spoken confirmed that health and safety training was undertaken in food hygiene, infection control, first aid, moving and handling and fire safety and this was confirmed on training records seen, which stated that this training had occurred between January and April 2009. The written information supplied by the service stated that maintenance checks were undertaken regularly; records seen in the home confirmed that portable electrical appliances had been tested in May 2009, electrical wiring had been checked in 2006 and gas safety in May 2009. 23 Cecil Road DS0000067816.V376414.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 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 25 23 Cecil Road DS0000067816.V376414.R01.S.doc NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 2 Refer to Standard YA12 & YA33 YA32 Good Practice Recommendations Staffing should be reviewed to ensure there are always sufficient staff available to enable chosen activities to take place. There should be 50 of staff with a National Vocational Qualification at level 2. 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@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. 23 Cecil Road DS0000067816.V376414.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!