Care Home: 23 Duston Road

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What the care home does well The survey questionnaire information received from the people living in the home was positive. One person said that they would tell ’the staff in charge of the shift’ if they were not happy. It was also said that if ‘I forgot’ how to make a complaint ’it’s on the notice board’. One person said ‘I like living here’. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Another person said that ‘I was fortunate enough to have a look around the place and even stayed over for several nights before moving in’. The people spoken to said that they all wanted to move into this home and one person said that ‘I love living here’ and another person said that ‘I visited this place and I loved it here’. The people say that they like the food and they have meetings to discuss activities and food. One survey questionnaire received from a relative stated that ‘from what I have seen so far every thing seems alright’. The staff spoken to say that the training received at the home is good. This is so they can better meet the people’s needs. One staff said that the induction ‘helped me to understand my role better’. Another person told us that ‘I always have the support of my senior team members and manager’. The staff also told us that the people get good care and they like looking working at the home. What has improved since the last inspection? The requirements from the last inspection were met What the care home could do better: All the people must be provided the opportunity to be involved in drawing up their care plans and to ensure that they are signed by them or their representative. This is so they know how their goals and aspirations. Ensure that the date and the names of the people involved in the assessment process are recorded in full. This is so people know who was involved in this process. Ensure all the people or their representative sign the contract. This is so that they understand what their rights and responsibilities are whilst living at the home. Ensure that sufficient information is recorded in the risk assessment to minimise the risk in that activity. Ensure that the bathroom and kitchen are kept clean at all times. This is to minimise any spread of infection to the home.23 Duston RoadDS0000043835.V375071.R01.S.docVersion 5.2Ensure that all staff references are received from their previous employer. This is to make sure that the person is suitable to work in the home. Ensure that CQC is informed of all incidents/accidents reportable under Regulation 37 Notifications. This is so we know that the home is following the right procedures in dealing with the incident. Key inspection report CARE HOME ADULTS 18-65 23 Duston Road Duston Northampton Northants NN5 5AR Lead Inspector Ansuya Chudasama Unannounced Inspection 22nd April 2009 09:45 23 Duston Road DS0000043835.V375071.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 Duston Road DS0000043835.V375071.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 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 23 Duston Road Address Duston Northampton Northants NN5 5AR 01604 754559 01604 588276 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) The Richardson Partnership for Care Mr Brian Richardson, Mrs Jacqueline Richardson, Miss Laura Richardson, Mr Gregory Paul Cheater Ms Michele Shalini D`Souza Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Physical disability (1) of places 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No person falling within the category MD can be admitted where there are already 7 persons of category MD already in the Home. The Home can accommodate 1 Service User within the category MD who also has needs within the category PD. No person under 22 years and over 52 years may be admitted to the Home. The Service Users admitted to the home who fall within the category MD must have an Acquired Brain Injury 22nd May 2008 Date of last inspection Brief Description of the Service: 23 Duston Road is a care home providing personal care and accommodation for 10 service users with Mental Disorder (Acquired Brain Injury) one of whom may have an additional Physical Disability. The Home is located in a suburb of Northampton close to the local shopping centre of St. James and near to local pub and other amenities. The Home can be easily accessed by public transport and is approximately a mile and a half from Northampton Town Centre. The Home consists of a three-storey building offering single bedroom accommodation to all the people living in the home en suite facilities. The ground floor bedroom has an adjacent, specially adapted bathroom to cater for one Service User who may have additional physical disability. The Home does not have a lift and Service Users accommodated on the upper floors must be able to negotiate stairs. There are two lounges and a separate dining room. The Home has disabled access, parking to the front and Service Users are provided with a rear garden. As from 1st of April 08 the basic fee levels start at £2,104 per week. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies which require review of key standards for the provision of a care home for younger adults that takes account of the peoples views and information received about the service since the last inspection. Evidence used and judgments made within the main body of the report include information from this visit. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. The report refers to we this is because the report is written on behalf of the Care Quality Commission. The link inspector was accompanied by another inspector during the visit to the home. The registered manager and another manager from another sister home assisted with this inspection. During this inspection we tracked the care of three people who use this service. This involved reading their care records and also talking to them wherever possible to obtain their views on the service. We also spoke to some of the other people who live in the home. Some people in the home were not always able to tell us about their experiences due to the nature of their acquired brain injury. We therefore used observations of people’s state of well being and how they interacted with staff members and other people in the home. Documentation relating to staff recruitment, training and supervision, medication administration, complaints and health and safety were also examined. We had the opportunity to talk to some of the staff who were on duty and a tour of the home was also conducted. The care home’s surveys from staff and the people were sent back to the Care Quality Commission (QCQ) when we asked for this. What the service does well: The survey questionnaire information received from the people living in the home was positive. One person said that they would tell ’the staff in charge of the shift’ if they were not happy. It was also said that if ‘I forgot’ how to make a complaint ’it’s on the notice board’. One person said ‘I like living here’. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 6 Another person said that ‘I was fortunate enough to have a look around the place and even stayed over for several nights before moving in’. The people spoken to said that they all wanted to move into this home and one person said that ‘I love living here’ and another person said that ‘I visited this place and I loved it here’. The people say that they like the food and they have meetings to discuss activities and food. One survey questionnaire received from a relative stated that ‘from what I have seen so far every thing seems alright’. The staff spoken to say that the training received at the home is good. This is so they can better meet the people’s needs. One staff said that the induction ‘helped me to understand my role better’. Another person told us that ‘I always have the support of my senior team members and manager’. The staff also told us that the people get good care and they like looking working at the home. What has improved since the last inspection? What they could do better: All the people must be provided the opportunity to be involved in drawing up their care plans and to ensure that they are signed by them or their representative. This is so they know how their goals and aspirations. Ensure that the date and the names of the people involved in the assessment process are recorded in full. This is so people know who was involved in this process. Ensure all the people or their representative sign the contract. This is so that they understand what their rights and responsibilities are whilst living at the home. Ensure that sufficient information is recorded in the risk assessment to minimise the risk in that activity. Ensure that the bathroom and kitchen are kept clean at all times. This is to minimise any spread of infection to the home. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 7 Ensure that all staff references are received from their previous employer. This is to make sure that the person is suitable to work in the home. Ensure that CQC is informed of all incidents/accidents reportable under Regulation 37 Notifications. This is so we know that the home is following the right procedures in dealing with the incident. 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 Duston Road DS0000043835.V375071.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 23 Duston Road DS0000043835.V375071.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): 1,2,3,4,5, 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 people and their representatives are given information about the home and visits and overnight stays are encouraged so they are able to make a decision to find out if their needs can be met by the home. EVIDENCE: The home has a statement of purpose and a service user guide, which has information about the home. The manager told us that the people were given information about the home to help them decide if this place was right for them. It was also explained that both documents had been recently updated to ensure that all information is accurate and current. We were told that the home assesses potential people to make sure that they can offer them a service which will meet their needs. The people are encouraged to visit and have trial overnight stays. This is so the person is given the opportunity to find out what it is like to live in the home and if they want to stay. One person said that ‘I was fortunate enough to have a look around the place and even stayed over for several nights before moving in’. Another person told us that they had ‘viewed the place and had a good feeling 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 10 about it’. Their families and the funding authority had also visited the home with them. The people have contracts, which tells them of their rights and responsibilities but the ones we inspected was not signed by the person living at the home. The manager told us that this would be done and will include all the other information stated in the standard. The files of the people we case tracked showed that their needs had been assessed before they moved to the home, and that the information had been sought from a range of involved health and social care professionals. The assessment document did not have the date and the people involved in the process recorded in full. 23 Duston Road DS0000043835.V375071.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): 6,7,9,10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people have care plans but this needed to be further developed to ensure that all the people or their representative are involved in drawing them up so they know how their goals are being met at the home. EVIDENCE: Each person who lives at the home has an individual plan of care, these contained good information about their needs and aspirations and covered areas such as cultural needs; Continence; Eating and drinking; Health; Memory; Personal care; Personal finances; Personal relationships; Physiotherapy and Social interaction with community. Care plans seen were signed by the person’s key worker but they had not been signed by the person themselves. We were told by people spoken to that they were not involved in 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 12 drawing up their care plans. One of the home’s service user satisfaction questionnaire read stated that the person ‘would like more involvement with care planning and risk assessments’. It is important that where possible people sign their care plans as this shows that they have been involved in agreeing how they would like to be supported and cared for. The registered manager stated that people were involved in agreeing their care plans and explained that the staff were due to receive training in the near future on person centred planning (PCP). Once this training has taken place the registered manager told us that everyone living at the home would be supported to devise their own PCP. The staff told us that they had monthly meetings about each individual person in the home. This was to monitor how their care needs were being met. We were told by staff that the home had meetings every three week with the people to discuss activities, meals, and any thing that was happening in the home. We observed staff asking the people what they wanted to do as well as giving choices for them to choose from. Records show that risks to people living at the home or the staff who support them have been assessed and steps taken to reduce any risks identified to an acceptable level. Risk assessments seen were generally comprehensive however one assessment for one of the people case tracked did not contain some specific information that potentially increased the risk in that area. This was raised with the registered manager during the inspection. The people’s files were kept secured in the manager’s office. 23 Duston Road DS0000043835.V375071.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: 12,13,14,15,16,17 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 people are provided with activities to increase their independent living skills. EVIDENCE: An activity schedule for each day is available on an orientation board in the hall way. The registered manager explained that the programme of activities had been recently reviewed and updated to give people more variety and choice. On the day of inspection some people were going to the Headway and Workbridge day centre and some others to Brixworth Country Park. One person told us that they played bingo, quizzes, did cooking once a week and watched films in the home. They also helped with clearing up after having 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 14 lunch and washed up afterwards. They went out to play snooker, bowling and went home for weekends. It was stated that the staff ‘treated us as adults with feelings’ and ‘not talk down to them’. One person told us ‘I like living here, I can go out and have people visit me.’ Another said “I am going out for a Chinese meal on my birthday’. We were also told that ‘agreements have to be made depending on appointments, staffing, what all the other service users want to do’ and ‘usually if you want a request it gets planned in’ when they want to do some thing. Another person said that ‘I would love to live on my own. I have to work towards this with the OT’s, care plans, and risk assessments’ to work towards this’. Another person told us that ‘I like living here but would like to live in own place one day’. One survey questionnaire from a relative stated that ‘from what I have seen so far every thing seems alright’. We were told that the people visited their families and some of them visited the home. Some people went to visit their families with staff support. The manager told us that people have a holiday each year and that they were all involved in deciding where to go. Lunch on the day of inspection was chicken curry served with rice or chips. Staff explained that people were given a choice of food and that they were asked each morning what they wanted. One person told us ‘I cook my own meals – I don’t like what the other have. Sometimes I don’t eat meat’. Another person told us that ‘food is quite nice’. Staff were observed sitting with one person, offering sensitive support while they were eating. Napkins were available for people in the dining room. 23 Duston Road DS0000043835.V375071.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): 18,19,20 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. The people’s health care needs are met by the home. EVIDENCE: There was evidence that people had involvement from a range of health and social care professionals including general practitioners, psychiatrists, psychologists, physiotherapists and occupational therapists. This was to ensure that the people’s needs were being met. Individual plans of care included assessment of people’s nutritional needs and any risk of pressure sores. We observed staff transfer a person from a chair. This was done very nicely with staff explaining to the person each step being carried out to help reassure them that they were doing well. We were also told that one of the people was 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 16 getting the proper equipment needed to meet their needs and this was welcomed by all. The people spoken to say that they choose their own clothes and some of them were able to do their own personal care. The administration of medication appears to be well managed. Each person has a medication profile that details the medication that they take. Two staff members sign the medication administration record which reduces the likelihood of errors occurring. The home did not have a facility to store any controlled drugs. There are laws and regulations about how these drugs should be stored and administered. Although no one at the home is currently prescribed any controlled drugs the home needs to make sure that safe storage is available should anyone be prescribed them in the future. This is also necessary to ensure that the home comply with the latest requirements of the Misuse of Drugs Act Amendment 2007 which stipulates how care homes should store controlled drugs. This was brought to the attention of the registered manager during the inspection and she ordered a controlled drugs cupboard to be fitted the following week. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 17 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): 22,23 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. Staff listens to the people’s views to ensure that their needs are met. EVIDENCE: The home has a complaints procedure that details how people should raise any concerns that they may have. The registered manager stated that no complaints have been received since the last inspection. One person spoken to said that if they were concerned about anything, they would speak to their key worker. Several other people spoken to said that if they were not happy, they would tell their friend, family or staff on duty. One family comment said that they knew how to make a complaint and also know who to speak to if they had any concerns. The home has made eight referrals to the Local Authority under the locally agreed safeguarding adult’s procedure. This ensures that, where someone living at the home may have been harmed by someone else, a full investigation can take place and measures put in place to keep people safe. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 18 The registered manager explained that the home does not use full physical restraint. Records show that staff receives training in how to intervene in a situation to de-escalate any conflict. Staff spoken to had good understanding of the people’s behaviours to know if they were unhappy. We were also told that there were guidelines in how to manage people’s challenging behaviours. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 19 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): 24,30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable, and has a rolling programme to improve the decoration, fixtures and fittings to meet the needs of the people EVIDENCE: The home is spacious and generally well maintained although there were some areas such as the sofas in the lounge which were showing signs of wear and tear. The registered manager explained that these were being replaced and that the people who live at the home were involved in choosing a new colour scheme. Communal areas, consisting of the main lounge, dining room and small lounge had been made homely with pictures and vases of flowers. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 20 The registered manager stated that decorators were due to come in the day following the inspection as part of the ongoing programme of maintenance. The home usually employs a cleaner however this post is currently vacant. The registered manager explained that someone had been appointed and was due to start in the near future; In the meantime staff were being given additional hours to complete the cleaning. The home was generally clean; however the communal bathroom and kitchen were in need of cleaning. One person told us that the home is usually fresh and clean and the manager ‘tells the staff to clean it when it is a mess’. Bedrooms seen had been made personal with pictures, ornaments and personal effects. One person showed us some impressive artwork that they had done at Headway, which was displayed on their bedroom walls. The home has an enclosed garden at the rear which has some garden and a shelter for people who want to smoke. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36 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 staff have good understanding of the people’s support needs to ensure their needs are met. EVIDENCE: Records show that staff generally have the necessary pre appointment checks to make sure that they are suitable to work with people with acquired brain injuries. One member of staff had a character reference as there second reference instead of a reference from a past employer. This was brought to the attention of the registered manager who stated that this was not usual practice and contacted the company’s recruitment officer to look into why this had occurred. New staff are given a comprehensive induction, which includes shadowing an experienced colleague and working through an induction booklet. One staff said that the induction ‘helped me to understand my role better’. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 22 The Staff files showed that staff have regular supervision sessions which are documented and signed by the staff member and manager. We were told that ‘in house training is good and service users are cared for well’. However it was said that more bank staff is needed because when staff go off sick or on holiday, it is some times difficult to meet all the needs of the people. The training records showed that the staff were receiving good training for the people that they were looking after. The Staff spoken to showed a good understanding of people’s needs and were observed talking to and interacting with people in a positive and caring manner. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 23 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): 37,39,42 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 views of the people are undertaken to ensure they benefit from a well run home. EVIDENCE: The manager is qualified and has worked in care for many years. One staff spoken to stated that they get support from the team and the manager. It was also stated that the staff work well as a team and get support from senior staff. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 24 The company employs an auditor who visits the home each week. He conducts some of the checks on the home that registered providers are required to carry out. The manager explained that these checks are overseen by one of the company partners who also visited the home. The home carries out regulation 26 visits to monitor how the home is doing. We were told that the home had recently sent out ‘service user satisfaction questionnaires’ and had two surveys returned. The two questionnaires read had positive things recorded about the home as well as things that needed looking at to meet the people’s needs. The analysis from the questionnaires needs to be made available to the people. This is so they know the outcome of the survey and know the action plan being put in by the management to meet any points raised by them. We had a discussion with management about sending questionnaires to staff and other stake holders involved with the home. This was to get their views on how the home is achieving the people’s goals. The people who live at the home have monthly house meetings with staff to discuss the home, garden, food and drink and activities. The staff have all completed the safe working practices to ensure all the people are kept safe. They also get fire drill training and weekly fire alarm and monthly emergency testing takes place. Risk assessments for the environment are recorded to minimise risk to the people and people working at the home. The home had not informed CQC of an important incident/accident that had happened at the home under regulation 37. We were informed of this incident by an anonymous call. This was discussed with the manager who apologised and said that they had lots of things to do. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 25 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 2 3 3 4 3 5 2 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 2 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 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 x 3 x 3 x x 2 x Version 5.2 Page 26 23 Duston Road DS0000043835.V375071.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. 1 Standard YA6 Regulation 15 Requirement All the people must be provided the opportunity to be involved in drawing up their care plans and to ensure that they are signed by them or their representative. This is so they know how their goals and aspirations will be met and they agree to them. Timescale for action 30/07/09 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 2 3 4 Refer to Standard YA2 YA5 YA9 YA30 Good Practice Recommendations Ensure that the date and the names of the people involved in the assessment process are recorded in full. This is so people know who was involved in this process. Ensure all the people or their representative sign the contract. This is to ensure that they understand what their rights and responsibilities are whilst living at the home. Ensure that sufficient information is recorded in the risk assessment to minimise the risk in that activity. Ensure that the bathroom and kitchen are kept clean at all times. This is to minimise any spread of infection to the DS0000043835.V375071.R01.S.doc Version 5.2 Page 27 23 Duston Road home. 5 6 YA34 YA42 Ensure that all staff references are received from their previous employer. This is to make sure that the person is suitable to work in the home. Ensure that CQC is informed of all incidents/accidents reportable under Regulation 37 Notifications. This is so we know that the home is following the right procedures in dealing with the incident. 23 Duston Road DS0000043835.V375071.R01.S.doc Version 5.2 Page 28 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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. 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