Care Home: 230a Mountnessing Road

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What the care home does well People get good information about the home and it is available in pictures as well as words. People are helped to choose what they want to do and when they want to go to bed and when they want to get up. People are supported to do lots of different activities both in and out of the home. The home is clean and tidy. Staff are experienced and well trained. What has improved since the last inspection? Medication checks are now done every week. The staff duty roster is much clearer.230a Mountnessing RoadDS0000015548.V377028.R01.S.docVersion 5.2Staff records are now kept in the home. There is good information about agency staff. What the care home could do better: The manager has to make sure that people have a healthier variety of food for their meals. There must be clear instructions to staff when any medication is disguised in food. The complaints policy must show that the home is regulated by the CQC and have our contact details in it. All staff should have supervision at least six times each year. Key inspection report CARE HOME ADULTS 18-65 230a Mountnessing Road 230a Mountnessing Road Billericay Essex CM12 0EH Lead Inspector Pauline Marshall Key Unannounced Inspection 10th August 2009 09:35 230a Mountnessing Road DS0000015548.V377028.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. 230a Mountnessing Road DS0000015548.V377028.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 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 230a Mountnessing Road Address 230a Mountnessing Road Billericay Essex CM12 0EH 01277 632914 01277 632914 yolanda.inciong@estuary.co.uk 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) Estuary Housing Association Limited Yolanda Inciong Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 230a Mountnessing Road DS0000015548.V377028.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 with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 8 2. Date of last inspection 29th August 2008 Brief Description of the Service: 230a Mountnessing Road provides eight people with learning disabilities with permanent accommodation. The home is two semi-detached bungalows that are joined together and is owned by Estuary Housing Association and has eight bedrooms, two lounges, two dining rooms, two kitchens, a laundry room, a shower room with a toilet and a bathroom with a toilet. The home has its own mini bus and is near the local shops and Billericay town centre. There are buses and trains nearby. This means that the people who live at the home can get around easily. Everybody who lives at 230a Mountnessing Road has their own bedroom. Nobody has to share a room. There is a weekly charge of £1,758.84 and people living in the home pay between £69.90 and £108.10 each towards this. There are extra charges for hairdressing, chiropody and activities in the community, sensory sessions and aromatherapy at home. 230a Mountnessing Road DS0000015548.V377028.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 1 star. This means the people who use this service experience adequate quality outcomes. We visited the home and looked at some of the resident and staff files. We also looked at the policies that explain how the home does things. We looked around the home and spoke to the staff and the manager. We read the information (AQAA) sent to us by the manager. We talked to people living in the home and watched what was happening. We sent surveys to people living at 230a Mountnessing Road and to some of the staff to see what they think about the home. What the service does well: What has improved since the last inspection? Medication checks are now done every week. The staff duty roster is much clearer. 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 6 Staff records are now kept in the home. There is good information about agency staff. 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. 230a Mountnessing Road DS0000015548.V377028.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 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 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. People receive sufficient information about the service and their needs will be fully met. EVIDENCE: The manager last reviewed the home’s Statement of Purpose in April 2009 and the Service User Guide in July 2009; both documents included up to date information about the service that included recent changes to Estuary Housing Association’s head office address. There is a separate poster detailing the Commission’s contact details and this was displayed on the home’s notice board. There have been no admissions to the home since the last inspection but there is a detailed admission policy and procedure for use in any future admissions. We looked at three care files and they contained thorough assessment documentation, which included information that had been provided by other professionals and covered all areas of physical, social and emotional needs. 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 9 Each of the care files that we looked at contained a pictorial copy of the individual’s contract, which detailed their terms and conditions with the home. 230a Mountnessing Road DS0000015548.V377028.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, 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. People receive appropriate individualised care based on identified needs. EVIDENCE: We looked at three of the care files and they included loads of information about each individual’s needs, wishes and goals. There were two support files in place for each person, which included support plans, risk assessments, monitoring charts, health notes and reviews. The support plans were very detailed and person centred and they looked at all areas of care such as personal care, communication methods, relationships, activities, eating, work and education, managing finances, and they all contained a health action plan. All of the risk assessments included plans on how the risks were to be managed. Each of the support plans and risk assessments that we looked at 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 11 had been regularly reviewed and they showed the date and the signature of the staff member reviewing them. The daily notes were detailed and informative. The people living at 230a Mountnessing Road have communication difficulties and express their views in various forms mainly using gestures and facial expressions; staff working alongside people on a daily basis has a good understanding of their different communication types. There were notes of meetings that had been held for people living in the home where activities, food and other issues affecting people’s daily lives were discussed. The manager said in her AQAA “service users are empowered to make their own decision which is shown in their Person Care Profile (PCP), risk assessment & care plans, bedrooms decoration and furninshing”. Staff spoken with confirmed that regular meetings are held where they support the person they are key worker to in discussing issues about the service that they receive and people indicated when spoken with that they had been involved. 230a Mountnessing Road DS0000015548.V377028.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, 17 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. People are supported to live a lifestyle that meets their identified needs and preferences. The lack of a healthy balanced diet could be detrimental to people’s health. EVIDENCE: There is a whiteboard in the office that shows people’s planned activities for the week ahead. People living at 230a Mountnessing Road regularly access leisure activities in the local community such as meals out, trips to parks, the seafront and local theatres. There were photographs displayed around the home showing various leisure activities that people had undertaken and staff spoken with said that day trips are arranged using the home’s mini-bus to 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 13 transport people in wheelchairs. The activity notes showed that people enjoyed indoor activities such as puzzles, games, activity ball and aromatherapy. The home has a sensory room, which has light projectors, luminous carpet and a bubble tube; staff spoken with said that people use this regularly and entries in the daily notes and activities records confirmed this. Some of the people living in the home have regular visits from their family; others are visited on special occasions such as birthdays and Christmas. People are supported to attend local discos, and the day centre which helps them to maintain their friendships. Staff was observed throughout the visit interacting with people living in the home and they were seen to treat people respectfully, they explained their actions and allowed plenty of time for people to respond to them before carrying out any activity and people appeared relaxed and happy in staffs company. There were pictorial menu’s displayed on the dining room notice board. The deputy manager said that these were prepared by the night staff according to the planned menu and that should people require an alternative the displayed menu would be changed accordingly. We looked at the four week rolling menu, which offered people a good choice of nutritious, healthy and balanced meals. We then looked at the actual nutrition records and they showed that people had been provided with different meals to what was shown on the menu. We looked at the nutrition records of three of the people living in the home and we found that one person had not had any breakfast or lunch on the Tuesday and the Sunday and another person had not had breakfast or lunch on the Saturday and Sunday; the deputy manager said that staff had forgotten to complete the records. All other nutrition records that we looked at were fully completed. The meals shown on the nutrition records differed greatly from those shown as offered on the four week rolling menus for example the Wednesday supper was beef stew, vegetables and potatoes and the nutrition records showed that all of the people living in the home had eaten roast chicken. The nutrition records showed that in one week people had eaten chicken for their main meal three times, they also showed that people had eaten Cornish pasties for their lunch three times in one week and the other two days they had eaten sausage rolls and chicken drummers. The repetitiveness of this 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 14 diet, which was not as detailed in the home’s four week rolling menu, was discussed with the deputy manager, who agreed that too much pastry and processed foods would not provide the people living in the home with a healthy balanced diet. 230a Mountnessing Road DS0000015548.V377028.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal care in a way that suits them and their health care needs will be fully met, but they may not receive medication safely. EVIDENCE: We looked at three support plans and they detailed the way in which each individual was to be supported; staff spoken with confirmed that the support plans are clear and that they know the level of support that each person needs. The bathroom doors were kept shut whilst staff were providing people with their personal care. After speaking to staff, looking at the records and observing practice it was evident that routines such as mealtimes, bathing and household tasks are flexible and planned around the needs and preferences of the people living in the home. 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 16 Staff spoken with and surveyed said that the home provides appropriate equipment such as hoists, individual slings, an assisted bath, a shower and beds that can be raised and lowered. One staff member said in their survey “one Parker bath was not functioning for a while now; it was not quickly dealt with”. The deputy manager said that the bath needed a part that was no longer available and that a new bath was to be purchased; however, there is a second assisted bath that people can use until it is replaced. The home has an up to date medication policy and all of the medication is administered by trained nurses. A bottle/packet to mouth system is used and all medication is recorded on a mediform administration sheet. The mediform sheets showed that a weekly audit was undertaken to ensure that the medication was right. We checked a random sample of medication and its corresponding mediform sheets and it was all found to be correct. There were PRN protocols in place for the use of all as and when prescribed medication; these showed when, why and how the medication was to be taken. Each of the medication records that we looked at contained a drugs history that showed the changes that had been made to the individuals’ medication regime. We observed a medication round, where tablets were given to people with yoghurt and a warm fruit juice drink instead of water. The deputy manager said that the people using the service were unable to take the medication without using these methods. We checked the mediform sheet, the support plans and the risk assessments and we could not find any information to support this activity; the deputy manager confirmed that the method was not recorded anywhere. 230a Mountnessing Road DS0000015548.V377028.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be protected from harm and abuse and their concerns will be listened to and acted upon, but they will not know that the home is a regulated service. EVIDENCE: The manager said in her AQAA that the complaints procedure was last reviewed in July 2006, however at the site visit she provided a leaflet dated January 2008 entitled “We’re all ears” and an undated copy of Estuary Housing Association’s Customer Feedback Policy. The customer feedback policy provides details on how people can give compliments, comments and suggestions and how they can make a complaint. Neither of the documents provided for inspection contained the contact details of the Commission and there was no information to show that the service is regulated. There was a separate poster displayed on the notice board entitled “key contacts”, this showed the details of the Commission but did not explain our role and the information on the poster was not included in the policy that was provided for inspection. The customer feedback policy that was displayed on the notice board was dated March 2004 and the contents stated that people 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 18 can complain to the Commission and it gave our contact details as NCSC at Southend. The Southend office closed in 2007 and CSCI superseded NCSC in 2004. People using the service need to have access to a clear complaints procedure and the policy should show them that the service is regulated by the Commission. There have been no complaints received at the home since the last inspection. The home’s safeguarding policy was contained in a separate folder in the office and was dated December 2008; there was no information on the Southend, Essex and Thurrock guidelines. The manager said that she would be obtaining a copy of the guidelines and would store them in the safeguarding folder to enable staff to read them. There was a list of staff signatures and dates confirming that the documents in the safeguarding folder had been read and discussed. Staff spoken with had a good awareness of safeguarding procedures; there were copies of certificates for safeguarding training on each of the staff files that we looked at. 230a Mountnessing Road DS0000015548.V377028.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, comfortable, safe and clean environment. EVIDENCE: 230a Mountnessing Road consists of two large semi-detached bungalows that are joined together; the hallway is spacious and allows plenty of room for wheelchair users to manoeuvre. There are four bedrooms, a dining room, a lounge and a kitchen in each of the bungalows; and there are shared laundry facilities in the middle of the building. There are bathing facilities in both bungalows; however one of the assisted baths is not working. The manager said that the bath is beyond repair as the parts needed are no longer available and that it will be replaced shortly with a new assisted bath. 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 20 Each of the bedrooms contained many personal items and they have been decorated to suit individual tastes; they were homely and spacious. The communal areas were nicely decorated and the furniture was of good quality. There was a large sensory room that has a large bubble tube, luminous carpet and a new projector that projects colours and shapes around the room. Staff spoke with said that people used the sensory room on a daily basis and the daily notes confirmed this. New dining room tables and chairs have been purchased since the last inspection. The maintenance file showed that repairs are carried out in a timely manner and staff spoken with confirmed that important jobs are carried out as soon as possible after they are reported. All outward opening doors have warning signs both inside and out reminding people to open them carefully. The home is kept clean by the care staff; there is a cleaning rota that showed that night staff are responsible for cleaning kitchen equipment, floors and bathrooms. Staff signs to confirm that tasks had been carried out and a check on the previous night’s tasks (cleaning the ovens/microwaves and toasters) showed that they had been carried out as planned. There is a ramp that allows wheelchair access to the large garden that has raised flower beds and plenty of seating areas. The manager said that people living in the home help staff to plant flowers and shrubs in the raised beds and staff confirmed this. The home was safe, clean, pleasant and hygienic. 230a Mountnessing Road DS0000015548.V377028.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): 32, 33, 34, 35, 36 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. People are cared for by a competent, well-trained staff team, who are safely recruited. The lack of regular staff supervision could leave staff feeling unsupported therefore placing people using the service at risk. EVIDENCE: The duty roster showed that there was sufficient numbers of staff on duty throughout the past two weeks. The planned duty roster showed that any vacant shifts were to be covered by either regular staff or agency staff. The deputy manager said that a monthly duty roster is drawn up together with a weekly working duty roster and that both are amended to show any changes when necessary. Both duty rosters were clear and showed a key to any abbreviations, they were both written in ink and changes were clearly identified. There is a qualified nurse working on each day shift supported by three support workers and in addition to this the manager works 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 22 supernumerary three days each week. One qualified nurse and one support worker work throughout the night. The manager said in her AQAA that three support workers have achieved their NVQ level 2 or above and the staff files confirmed this. Six of the home’s staffs are qualified nurses and the deputy manager is working towards her NVQ 3 in management. We looked at three of the staff files and they all contained a completed application form, two written references and details of their induction. The two newest staff files did not contain original criminal records bureau (CRB) checks, however there was documents from Estuary Housing Association’s head office confirming that a CRB check had been carried out. We advised the deputy manager to obtain the CRB guidance off our website as the original CRB should be retained on the staff file until it has been inspected by us. We looked at the staff training folder and found certificates for food hygiene, moving and handling, first aid, safeguarding, risk assessment, health and safety, fire awareness and medication. There were also certificates of training for more service specific subjects such as epilepsy, dementia, challenging behaviour and palliative care. Staff spoken with said that the training offered by Estuary Housing Association was good and that they were offered regular updates. We looked at a random sample of the agency profiles for some of the regular agency staff that work in the home and they showed that the agency staff had regular updates in their training and staff spoken with and surveyed confirmed this. The last staff meeting was held on 27/06/09 and subjects such as teamwork, resident issues, operational issues and updating of care files were discussed. The manager said that staff meetings are generally held after the managers have met, so that information obtained there can be fed back to the home’s staff. We looked at the supervision records belonging to three staff and we found that although supervision does take place, it is not as regular as required in the National Minimum Standards. One staff file showed that supervision had been provided three times in one year, another showed that supervision had taken place twice in one year and the third staff file showed that the person had been employed since April 2009 and had not yet had supervision. The importance of regular supervision was discussed with the deputy manager and the manager. 230a Mountnessing Road DS0000015548.V377028.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. People live in a well run home that is run in their best interests. EVIDENCE: The manager is an experienced qualified nurse and she has worked at 230a Mountnessing Road for some years, she has completed the registered managers’ award and regularly updates her practice. The manager has undertaken training in first aid, food hygiene, moving and handling, fire safety and safeguarding in the past year. 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 24 The manager completed her annual quality assurance assessment (AQAA) and it contained the information that we had asked for. The deputy manager said that the home has regular visits from the provider and there were reports to show that these have taken place on a regular basis. Although the home does not hold people’s individual cash, there is a weekly float of £500 available to staff to enable them to purchase personal items on behalf of the people living in the home. A weekly return (plus any receipts) is made, showing the amounts spent for each individual and it is sent to Estuary Housing Association’s head office; any money spent is reclaimed from the individuals’ bank account. We looked at a random sample of the home’s safety certificates and they were found to be in place and up to date. The home has a fire risk assessment dated 15/07/08 and regular fire drills take place, the last one recorded was on 03/08/09. 230a Mountnessing Road DS0000015548.V377028.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 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 3 33 3 34 3 35 3 36 2 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 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Version 5.2 Page 26 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Are there any outstanding requirements from the last inspection? yes 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 YA17 Regulation 16 (2) (i) Requirement The manager must ensure that people living in the home are provided with a healthy balanced diet. To ensure that good nutrition provides them with a healthy lifestyle. The manager must ensure that there are safe methods in place for administering medication and that there are clear risk assessments and instructions to staff informing them of the need to disguise any medications. To ensure that people receive their medication safely. The manager must ensure that the complaints policy shows that the home is a regulated service and that it provides people with the Commissions contact details. To ensure that people have the correct information. Timescale for action 30/09/09 2. YA20 13 (2) 30/09/09 3. YA22 22 (7) (a) 30/09/09 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 27 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 YA36 Good Practice Recommendations It is recommended that the manager provides all staff with supervision at least six times a year to ensure that they are supported to carry out their work. 230a Mountnessing Road DS0000015548.V377028.R01.S.doc Version 5.2 Page 28 Care Quality Commission East 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). 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