Care Home: 3 Paradise

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What the care home does well People’s needs are assessed, so that their care and support can be properly planned. People have detailed care plans, so that staff have clear guidance about how to support them in ways that suit them best and keep them safe. Plans are reviewed regularly, so that important information can be kept up to date. Staff support people to do things they enjoy, go to places they like and keep in touch with the people who are important to them. They work hard to arrange things for people to take part in. They help to plan menus and get involved in shopping for food, so that they can have the things they like. This helps to ensure they enjoy their food and mealtimes. People are generally well looked after. They get the support they need to keep important medical appointments and to get their medicines when they should. Staff support them to stay healthy and well. The care team is well motivated and keen to provide a good service. They treat people with respect, friendliness and warmth. Important checks are carried out on staff to ensure that they are fit for their jobs. The service is generally well run. People feel that they can approach the management team with any concerns. They are confident that any issues are listened to, taken seriously and acted upon. Important checks and 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 maintenance gets done on essential equipment in the home. This ensures that people living and working there can stay safe. What has improved since the last inspection? The Manager and staff have continued to work hard to make sure that people get all the support they need, and to meet recommendations made at the last inspection. It should be acknowledged that the relatively short time between inspections is only because of change in registration status of the company. Systems have now been put in place to keep a record of any medication returned to the pharmacy. Some efforts have been made to improve the frequency of formal supervision for staff, and this continues to be a work in progress. The staff team remains consistent, so that people benefit from being supported by workers that are familiar to them, and understand their needs well. What the care home could do better: Care plans should be developed by extending the use of person-centred approaches, and setting clear goals. This will help to ensure that people are supported in ways that suit them best. It also means they should get the support they need to achieve the things they say are important to them. Developing Health Action Plans could help to ensure that their good health is more actively promoted, to keep them fit and well. Medication Administration Records should be completed at the same time that medicines are given. This is to ensure that people get their medicine in the right doses at the correct times. Make sure that staff receive regular formal supervision and annual performance appraisals. This is to ensure they get all the support they need to do their jobs well. Complete work on quality assurance and monitoring, and produce a report of the findings. This is so that it can be clearly seen how people’s views have been taken into account, in developing the service for their benefit. Key inspection report CARE HOME ADULTS 18-65 3 Paradise Dudley West Midlands DY2 8SH Lead Inspector Gerard Hammond Key Unannounced Inspection 10th September 2009 09:30 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service 3 Paradise Address Dudley West Midlands DY2 8SH 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) 01384 240502 Grazebrook Homes Ltd Mr Adnan Iqbal Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 3 The maximum number of service users to be accommodated is 3. 2. Date of last inspection (27 January 2009 – under previous registration) Brief Description of the Service: 3 Paradise is registered to provide accommodation, care and support for three people with learning disabilities. The home is part of a well established small network of services run by the company in this neighbourhood. The house is a domestic scale semi-detached property in a residential area near to the centre of Dudley. Local shops and other amenities are close by, and the area is well served by public transport. There are three single bedrooms, two on the first floor and one on the ground floor. There is a bathroom and toilet upstairs, and a shower room and toilet downstairs. There is no lift. Shared spaces include a large kitchen, laundry / utility room, comfortable lounge and separate dining room. There is an enclosed garden at the back of the house. Limited parking is available on the drive at the front. The home should be contacted directly for current information about fees and charges. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is Two Stars. This means that the people who use this service experience good quality outcomes. This is the home’s first key inspection of the current year 2009-10. The home was last inspected on 27 January 2009. This inspection was required following the organisation’s change of status to a limited company. We gathered information from a number of different places to help us make the judgements found in this report. The Manager sent us a completed Annual Quality Assurance Assessment (AQAA) when we asked for it. This is a self assessment about how well the service is doing, and provides some numerical information about it. We visited the home and met with people who use the service, the Manager and members of the staff team. We looked at records including personal files, assessments and care plans, staff files, safety records, previous inspection reports, and other documents. What the service does well: People’s needs are assessed, so that their care and support can be properly planned. People have detailed care plans, so that staff have clear guidance about how to support them in ways that suit them best and keep them safe. Plans are reviewed regularly, so that important information can be kept up to date. Staff support people to do things they enjoy, go to places they like and keep in touch with the people who are important to them. They work hard to arrange things for people to take part in. They help to plan menus and get involved in shopping for food, so that they can have the things they like. This helps to ensure they enjoy their food and mealtimes. People are generally well looked after. They get the support they need to keep important medical appointments and to get their medicines when they should. Staff support them to stay healthy and well. The care team is well motivated and keen to provide a good service. They treat people with respect, friendliness and warmth. Important checks are carried out on staff to ensure that they are fit for their jobs. The service is generally well run. People feel that they can approach the management team with any concerns. They are confident that any issues are listened to, taken seriously and acted upon. Important checks and 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 6 maintenance gets done on essential equipment in the home. This ensures that people living and working there can stay safe. 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. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 7 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 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’s strengths and needs are assessed, so that their care and support can be properly planned. EVIDENCE: There have been no new admissions to the home since we last visited. The three people living there have been together since the home opened in 2005. We looked at their personal records and saw that each individual has a detailed assessment of his strengths and support needs. This is important, as it provides a sound basis for planning their care and support. We saw that assessments have been reviewed, to make sure that important information is kept up to date. The last inspection report (completed under the home’s previous registration) shows that a Statement of Purpose and Service Users’ Guide are in place as required. We did not look at these documents on this occasion. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 get the support they need in ways that they like, and ensure they can stay safe. They get the help they need to make decisions about things that are important to them. EVIDENCE: We looked at people’s personal records to see how their support is planned and managed. All of the files we looked at contained a detailed care plan, and we saw that these had been kept under review regularly. We saw that care plans include risk assessments, so that people get the support they need to stay safe. The Manager told us that a review is scheduled with the Local Authority Social Worker in the near future. This is important, as it helps to ensure that plans are kept up to date. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 11 We talked to the Manager about care planning and recommended that the use of person-centred approaches be developed. Also, that care plans include clear goals with outcomes that can be measured. These should be evaluated regularly, so that judgements can be made about what is working and what might need to be changed. Doing these things should help to ensure that people get the support they need in ways that suit them best. We saw and heard staff asking people what they wanted to do, and supporting them in making decisions and choices. It is clear that they enjoy a good rapport. One person wanted to come home early from his day centre, and he was able to do this. The three residents are looking forward to going away on holiday soon, and said that they had chosen where to go. We saw records of house meetings to discuss activities, menus, holidays and so on. The last inspection report shows that people have also been supported to access independent advocates, to ensure their interests are properly taken into account. These things show that people are directly involved in making decisions, to promote their individual independence. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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, 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. EVIDENCE: We talked to people and looked at their records, to find out what opportunities they have to do things they value. We saw that people go to local day centres regularly for structured activities during the week. Changes to services the Local Authority provides has meant that this has reduced over the past twelve months. Records show (and people told us) that they use local facilities such as the shops, park, pubs, clubs and restaurants regularly. As reported above, people are looking forward to going away on holiday in the near future. The “parent organisation” (Grazebrook Homes) has a real presence in the local community. It is a family business: the Owner and the Manager grew up in the 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 13 neighbourhood and still live there. The service provides a small network of homes in the vicinity, and people living in them know each other well and keep in touch with each other. They visit and do activities together, according to what they want. People are well known and enjoy the benefit of good neighbours. Their records also show that they get the support they need to keep in touch with their families and friends. We looked at the stocks of food in the house and saw that these were plentiful. They included fresh fruit and vegetables and salad items. We saw a pictorial menu plan. This works on a “rolling” four-week cycle, and people told us they had helped to put this together. We saw their individual food diaries and these showed that they enjoy plenty of variety and choice. One of the people told us “The food is good. We help with the shopping and we can have what we want.” Another person said “I’m very happy here”. We talked to the Manager about activity planning and recommended that some clear links be established between people’s agreed goals and their activity opportunities. This is to ensure that they get all the support they need to do the things they say are important to them. This recommendation is made merely as a matter of good practice, to build on the good work already being done in this area. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 & 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. People’s health and personal care needs are generally well met. EVIDENCE: We saw that people were well dressed in clean, good quality clothing that was age and gender appropriate. They had clearly received the support they needed with personal care and hygiene. We were able to directly observe interactions between people and the staff that look after them. These were warm and friendly, people are treated with respect and they are clearly at ease in each other’s company. Conversations with staff showed that they have a good knowledge and understanding of the particular ways and important “little details” of the people in their care. As reported above, they have detailed care plans that are kept up to date so that people get the support they need in ways that they like. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 15 We looked at people’s records to see how their healthcare is planned and managed. We saw that files contained records of appointments with doctors, consultants, opticians, dentists, social workers and other professionals. Records showed that advice and support is sought appropriately to ensure that people’s needs are met. We recommended that the service develops Health Action Plans for each individual. This is in keeping with the aspirations of the Government White Paper “Valuing People” (2001). Health action planning seeks to focus on proactively promoting individuals’ good health, as opposed to reacting when problems arise. Plans should be useful tools to manage people’s healthcare more systematically. It might be helpful to seek support to do this from the local Community Nurse (Learning Disability Team). As before, this recommendation is made to build upon existing good practice. The last inspection report shows that arrangements for managing medication within the home are generally satisfactory. Only one person is on regular prescribed medication. We saw that a recommendation made when we last inspected has been met. A “returns book” is now in place to keep a record of medication returned to the pharmacy. We looked at the Medication Administration Record (MAR) and noted that there were some gaps. This appears to be clerical error, as we could see that the medication had been removed from the “blister pack”. We spoke to the Manager about this, so that he can make sure that records are completed appropriately in future. We saw that medication is stored securely. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 & 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. People are confident that their concerns will be listened to, taken seriously and acted upon. They get the support they need to protect them from abuse, neglect or self-harm. EVIDENCE: The Manager told us (in the Annual Quality Assurance Assessment) that no complaints have been received by the home since the last inspection. We have not received any complaints about this service either. The last inspection report shows that appropriate policies and procedures are in place, dealing with complaints and safeguarding. It has to be acknowledged that the people living in this house rely on the vigilance of the staff to notice signs that something may be amiss. This might be changes of mood or behaviour, as indicators that something has upset or worried them. We asked people what they would do if this were the case. They said “talk to staff” and “tell (N)” (manager / staff). Conversations with the manager and staff on duty showed that they are sensitive to individuals’ particular ways and regular behaviour patterns, and understand these well. We talked to staff about safeguarding. They were able to show their understanding of the different forms abuse can take, and what might lead 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 17 them to suspect that someone might have been abused. They showed that they know the action they must take in the event of suspecting or witnessing abuse. We looked at staff records and saw that required checks with the Criminal Records Bureau (CRB) had been done before people started work. We saw certificates showing that staff had completed training in adult protection. These things show that the service takes positive action to ensure that people get the support they need to stay safe. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 & 30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to enjoy the benefit of living in comfortable, clean and homely surroundings. EVIDENCE: We looked around the house with the Manager, and people happily showed us their rooms. The house is a semi-detached domestic scale property. The home is comfortably furnished, well decorated and maintained to a very high standard. One of the bedrooms is on the ground floor; the other two are upstairs on the first floor. Shared spaces include a comfortable lounge, separate dining room, kitchen and laundry / utility room: all of these are on the ground floor. There are ample bathing facilities and toilets for the three men. These include a bathroom and toilet on the first floor, and a level entry shower and toilet on the ground floor. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 19 People proudly showed us their bedrooms. These are all individual in style and reflect the personality and interests of the occupants. They are comfortably furnished and decorated. We saw family photographs, pictures, ornaments, collections of DVDs, televisions and music players. It was clear that people like their rooms and enjoy spending time in them when they wish. There is an enclosed garden at the back of the house. This has a raised lawn, decked area, garden furniture and BBQ. At the front of the house there is parking space on the drive, and the local park is just across the street. Other amenities and shops are within easy walking distance. We saw that the house was fresh, clean and tidy. One of the residents said to us “I like it here”. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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, 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. Staff are trained, qualified and well motivated, so that people get the support they need in ways they like. Important checks are carried out, to make sure that staff employed are fit for their jobs. Arrangements for staff supervision and appraisal need continued development: this is to ensure that they get all the support they need to do their jobs well. EVIDENCE: We saw that sufficient numbers of staff are employed in the home to meet people’s assessed needs. This is principally for supervision and guidance: the three men living in the home have good independence skills. A review is planned to explore the feasibility of changing this service to a “supported living” scheme, to promote their independence further. Low turnover of staff promotes continuity of care for the people using the service. As reported above, it is clear that staff have good knowledge and understanding of the needs of the people they look after. They speak very positively about the residents, with warmth and affection. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 21 We looked at staff records to see how selection and recruitment of staff is managed. There have been no changes to the team since the last inspection. The files we looked at all contained completed application forms, two written references and checks with the Criminal Records Bureau (CRB), as required. This shows that the service takes positive action to ensure that people working at the home are fit for their jobs. The last inspection report shows that a staff training and development plan is in place. We saw certificates of recent training completed on the staff files that we looked at. The Manager told us that the induction process for new staff has now been reviewed, and is ready for implementation when any new staff start work. We saw that a new format has been put in place for recording formal supervision of staff. It has to be acknowledged that the small size of the home and the nature of the “parent organisation” mean that issues tend to get dealt with on a day-to day basis, as they arise. Formal supervision is still not yet up to the National Minimum Standard, but this is a work in progress. As previously recommended, this should also include provision for an annual appraisal of staff performance and development needs. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 & 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 is well run for the benefit of the people that use it. EVIDENCE: The home’s Manager is qualified to NVQ level 4 and appropriately trained and experienced to run the home. We saw that he enjoys a good rapport with the people in his care, and the staff working in the home. Both confirmed that he is very approachable and people are comfortable raising any matters of concern with him. We also met with the organisation’s “Responsible Individual” (owner / Senior Manager), who is also the Manager’s brother. As reported above, the company is a family concern, well known within the local 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 23 community. The Senior Manager is directly involved in the running of the service, and a regular visitor to the home. We talked to the management team about quality assurance and monitoring of the service. This is currently still a work in progress: information from questionnaires and other monitoring activity now needs to be collated and analysed. This should then be included in the home’s annual report and made available to all interested parties. It should show clearly how the views of people using the service have been taken into account in its review and development. We sample checked records relating to health and safety matters in the house and looked around the home. We saw that important checks and maintenance / servicing of essential equipment have been carried out regularly. This shows that the home acts positively to ensure that the people living and working there can stay safe. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 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 X 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 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 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 3 x Version 5.3 Page 25 3 Paradise DS0000073215.V377856.R01.S.doc Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Develop the use of person-centred approaches in individuals’ care plans. Set goals with measurable outcomes and evaluate them regularly. Doing this will help to ensure that people get the support need in ways that suit them best. Develop individual health action plans, to help ensure that people get all the support they need to stay healthy and well. Ensure that Medication Administration Records are fully completed at the time medicines are given. This is to ensure that people get their medication in the correct doses and at the right time. Ensure that staff receive regular formal supervision and an appraisal of their performance and development needs. This is to ensure they get all the support they need to do their jobs well. Complete quality assurance and monitoring activity, analyse the information gained, and make the report DS0000073215.V377856.R01.S.doc Version 5.3 Page 26 2. 3. YA19 YA20 4. YA36 5. YA39 3 Paradise available to all interested parties. This is to show how the home takes account of the views of the people who use the service. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 3 Paradise DS0000073215.V377856.R01.S.doc Version 5.3 Page 28 - 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!