Care Home: 38a Woolifers Avenue

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What the care home does well People get good information about the home. People`s support plans are in pictures as well as written. People are helped to choose what they want to do and what they want to eat. People are helped to go out to the shops and are well known in the area. People are helped to keep themselves healthy. The home is clean and tidy. What has improved since the last inspection? The information paperwork is kept up to date. There are now more medication checks to make sure that it is right. The manager now does all of the employment checks needed for new staff before they start work at the home. The home has new dining tables, chairs and flooring. What the care home could do better: 38a Woolifers AvenueDS0000018119.V376768.R01.S.doc Version 5.2 The manager should make sure that all copies of her complaints procedure show that the home is regulated by the Care Quality Commission. Key inspection report CARE HOME ADULTS 18-65 38a Woolifers Avenue 38a Woolifers Avenue Corringham Essex SS17 9AU Lead Inspector Pauline Marshall Key Unannounced Inspection 20th July 2009 09:05 38a Woolifers Avenue DS0000018119.V376768.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. 38a Woolifers Avenue DS0000018119.V376768.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 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 38a Woolifers Avenue Address 38a Woolifers Avenue Corringham Essex SS17 9AU 01375 640292 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) www.familymosaic.co.uk Family Mosaic Mrs Sarah Ann Burton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2008 Brief Description of the Service: 38a Woolifers Avenue provides three people with learning disabilities with permanent accommodation. This is a detached bungalow that is owned by Family Mosaic and has three bedrooms, a lounge diner, a shower room and a bathroom. The home has its own people carrier and is near the local shops, Lakeside and Corringham 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 38a Woolifers Avenue has their own bedroom. Nobody has to share a room. The manager can provide people with copies of the home’s Statement of Purpose and Service User Guide. The cost of staying at 38a Woolifers is between £1356.53 and £1377.00 per week and people pay a contribution of between £69.90 and £108.10 per week depending on their income. You will have to pay extra for some things such as toiletries, hairdressing and personal items. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good 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 38a Woolifers Avenue, their relatives and to the staff to see what they think about the home. What the service does well: What has improved since the last inspection? What they could do better: 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 6 The manager should make sure that all copies of her complaints procedure show that the home is regulated by the Care Quality Commission. 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. 38a Woolifers Avenue DS0000018119.V376768.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 38a Woolifers Avenue DS0000018119.V376768.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 will receive good information about the service and their needs will be fully assessed. EVIDENCE: The Statement of Purpose and Service User Guide is given to people before they move into the home and there were copies of the Service User Guide displayed in each person’s bedroom. The manager said that both documents had recently been reviewed and amended to include changes to the staff team. The documents showed that they had been amended to include up to date CQC details. A copy of the home’s last inspection report was in the folder holding the Statement of Purpose and Service User Guide. There have been no admissions since June 2008. We looked at three care files and we found that there was assessment documentation for the most recent admission, together with the transitional action plan, for the person that had transferred from another Family Mosaic Home. The two other care files did not contain copies of the pre-admission assessments made by the home, however they did contain copies of the assessments carried out by the social services. The manager said that the people have lived at the home since 1997 and 2003 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 9 and that the pre admission assessments may be archived. At the last inspection we looked at the pre-admission assessments that had been carried out by other managers for these two people and they were satisfactory. Each person living in the home had a pictorial tenancy agreement that set out their fees and charges and it detailed any additional payments that had to be made, such as hairdressing, toiletries and personal items. 38a Woolifers Avenue DS0000018119.V376768.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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive excellent individualised care based on their identified needs. EVIDENCE: We looked at all three care files and we found support plans that were well written, person centred and clearly explained the level of staff intervention that was required to support each individual. There were support plans in place for all areas of need, such as personal care, emotional care, sleeping, managing finances, activities and communication. Each of the support plans had been regularly reviewed and there were amendments to show that changes had been made when necessary to ensure that the home continues to meet the needs of the people living there. One of the support plans that we looked at included a list of meaningful activities; this list was meaningful to the person it was written for. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 11 People spoken with said that they were involved in their support plans and there were notes of their monthly one to one key worker meetings that confirmed this. The manager said in her AQAA “all of the people living in the home have had a community care review with outside health professionals, family members and advocates to ensure that their individual needs continue to be met”. There were copies of the reviews on each of the care files that we looked at. The manager said that regular meetings are held for people living in the home and there were notes of the meetings that confirmed this. Each of the care files that we looked at included risk assessments for all areas of identified risks such as activities, behaviour and health; there were management plans and guidelines accompanying each area of identified risk. There was paperwork to show that people’s rights were being looked at under the Mental Capacity Act 2005. All of the support plans, risk assessments and management guidelines had been regularly reviewed and updated. 38a Woolifers Avenue DS0000018119.V376768.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are well supported to live a lifestyle that meets their identified needs and preferences. EVIDENCE: We looked at the three support plans and they included a chart of weekly opportunities chart for each person, which formed the basis of their activity plans. Key workers explore possible new opportunities such as outings and excursions and people often go out in the people carrier for shopping trips. People spoken with said “I enjoy going to the charity shops and I buy things for myself such as puzzles and books”. At the last inspection the manager 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 13 spoke of her plans to introduce massage, music therapy and nail painting; the records showed that this has taken place as planned. The manager said that people are encouraged to maintain contact with their family and friends and people spoken with confirmed that they have regular visitors and one relative said in their survey “I am over the moon with the home; they make sure we keep in touch”. One person living in the home told us that they have regular visits from their family. The home has a four week rolling menu that is adapted to suit the preferences of the people living in the home and there is an alternative menu that offers a range of different meals including light meals and suppers. If people choose from the alternative menu, it is recorded in their individual food diary. People spoken with said they were able to have what they want to eat and the entries in the food diaries showed that this was so. The food stocks were good and there was plenty of fresh fruit available. The home uses the Food Standards Agency “Safer Food Better Business” system to record its catering and kitchen cleaning tasks. The dining room has recently been redecorated to the choice of the people living in the home and there are new dining tables and chairs. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 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 receive personal care in a way that suits them and their health care needs will be fully met. The home’s medication policy and practice will protect people from the risk of medication errors. EVIDENCE: Staff was observed interacting with people using the service throughout our visit and they were seen to be respectful, patient and caring in their manner. People using the service appeared relaxed and comfortable in staff presence, they chatted happily with the staff on duty. Staff said in their surveys “people are treated as individuals and continuous improvements make the home superb, modern and homely”. We looked at all three care files and each person had a clear health action plan; there were recorded details of all health care visits such as GP, nurse, chiropodist, optician, occupational therapist and consultant psychiatrists. The 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 15 outcomes of health care visits together with any follow up actions were recorded in the health care records. We checked a random sample of the medication and its corresponding records and we found that it was correct. The manager said in her AQAA “- Individual medication audits have been introduced which are completed weekly. The night staff checks medications as a night chore to pick up on any failings as soon as possible”. The audits that the home uses made it quite a lengthy process to confirm that the medication was right. The home uses a monitored dosage system and all staff has had training in its use; there were completed workbooks on staff files to confirm that they were competent to administer medication. Staff spoken with said that they felt that the medication training was good and that the workbook was a good reference guide. There was PRN protocols in place for all as and when prescribed medication. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 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 know that their concerns will be dealt with and that they will be protected from harm and abuse. EVIDENCE: There has been no complaints made in the past year; the home has a complaints folder ready for use should they receive any complaints in the future. There is a separate folder for recording any compliments that are received by the home. The complaints policy has been recently reviewed to show the role of the Commission and our new contact details. In addition to the full lengthy procedure there is a scaled down pictorial one, which gives people the details of Family Mosaic; it does not mention the Commission or the Commissions’ role. Each of the people living in the home had a copy of the pictorial procedure in addition to the information on complaints in their Service User Guide. All copies of the complaints procedure should show the role of the Commission and its contact details. One relative said in their survey “I know how to complain and would not hesitate to do so if needed”. We spoke to one relative over the telephone and they said they were so happy with the care and attention their relative received and that they had “no concerns whatsoever”, 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 17 but if they did they would talk to the manager or her staff and are confident that it would be dealt with. The abuse policy was reviewed in May 2008 and provides staff with a detailed account of the signs of abuse, the legal framework and the input of other agencies such as the police and social services. The abuse policy included a bullet pointed quick guide and works within the Essex Protection of Vulnerable Adults procedure (blue book). At the last inspection a discussion took place around the Southend, Essex and Thurrock guidelines that replaced the blue book in April 2008; the manager had not obtained these guidelines at the time of the visit, however, she has since confirmed that she now has a copy and that staff have been made aware of it. When spoken with, staff showed that they had a good awareness of safeguarding and that they had read and understood the home’s procedures. All staff has had safeguarding training and the manager said that it is regularly discussed at supervision sessions; the supervision notes confirmed this. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 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 environment. EVIDENCE: We looked round the building both inside and outside and all areas were found to be clean and tidy. The garden was well maintained and had a pathway with handrails to assist people with mobility problems. There is a grassed area with table, chairs, parasol and a hammock and there is lighting around the pathways so that people can enjoy the garden on darker evenings. The home’s people carrier is parked at the rear of the garden on some hard standing so that people have easy access when they want to go out. The manager said in her AQAA “each of the people living in the home has had their personal bedroom re-decorated this past year, to reflect their personal tastes 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 19 and personalities”. The bedrooms were personalised and included items that each individual enjoys, such as books, soft toys, pictures and a radio. People spoken with said that they are very happy with their rooms and that staff supported them to choose their decorating materials including their paint colours and soft furnishings. The washing machine and tumble dryer are situated in the newly fitted kitchen. The manager said at the last inspection that the second bathroom was going to be removed and the space used for a utility room. This has not occurred and the bathroom remains in place and the manager has said that one person using the service has enjoyed the occasional bath so the provider decided it would be better to leave the bathroom intact. The manager said that a new washing machine is due to be delivered later this week and that it will replace the existing one as it had broken down a few days earlier and staff were taking people’s laundry to a nearby home; there were records to confirm that this was so. The manager has a cleaning schedule that was fully completed and staff said when spoken with that they perform household tasks whilst on shift and people using the service sometimes work with them on this and one person said when spoken with that they enjoy tidying up. The home was clean, fresh and hygienic and relatives said in their surveys “it is always clean and tidy and I visit at various times, they don’t always know when I am going to visit” and another relative said “the staff keeps the home so nice”. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 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. People are cared for by a competent, well-trained and supervised staff team, who are safely recruited. EVIDENCE: The duty roster showed that there are two support workers throughout the day and one support worker awake at night. The manager works as part of the shift system, however, she works one shift each week supernumerary to enable her to carry out her management duties. The home employs several relief (bank) support workers, which minimises the use of agency staff. We looked at the last two weeks duty rosters and they showed that agency staff had been used on two occasions and that all other vacant shifts were filled by either the existing staff of relief staff. The manager said that there had been a recruitment drive recently and that one of the people interviewed was due to start work at the home in August, she also said that one of the candidates had been unsuitable for the post. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 21 We looked at three staff files including those of the two newest employees and we found that they contained all of the required information including copies of completed application forms, two written references, criminal records bureau checks (CRB) and evidence of staff fitness to work at the home. The manager said that the original recruitment documents are stored at Family Mosaic’s head office and that she has access to the scanned originals on the home’s computer system that is password protected. Staff spoken with and surveyed confirmed that the recruitment process was thorough and that they did not start work without the appropriate checks. The manager said in her AQAA “two staff have NVQ 3, one staff has NVQ 2 and another staff is working towards it; the staff records confirmed this. The three staff files that we looked at contained copies of certificates of training that included food hygiene, first aid, medication, safeguarding, moving and handling, fire awareness, health and safety and control of substances hazardous to health (COSHH). Staff spoken with and surveyed said that the training offered by the home was good and one staff member said that they had worked at the home for nine months and had been on ten different training courses and had undertaken a full induction. The records showed that staff had been provided with a full induction programme to the organisation and to the home. All of the staff files that we looked at contained notes of staff supervision sessions. Each staff member had a supervision contract and the manager said that she aims to provide this every four to six weeks. Staff spoken with and surveyed confirmed that regular supervision takes place and that they feel well supported by the management of the home. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 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 very experienced and has worked in care for more than twenty years; she has completed the registered managers’ award and regularly updates her practice. Recent training includes infection control, supervision, recruitment and selection, Mental Capacity Act, Deprivation of Liberties, fire, health and safety and COSHH (control of substances hazardous to health); she has also recently attended a learning disability conference. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 23 Regular meetings are held for people living in the home and people spoken with confirmed that they have their say on how the home is run; there was written notes describing the issues that had been discussed at the meetings such as food and activity choices. People surveyed including one health and social care professional that visits the home were very complimentary about the service saying that “it treats people as individuals and cares for them in a way they would choose” and “they look after people like they are their family, it is a fantastic service and they are very caring people”. The provider carries out regular monthly checks on the service and there were copies of the reports available for inspection. The last report showed that the provider asked about people’s experience of living and working in the home and their comments were recorded in the document. It looked at the progress of any planned improvements and identified any outstanding issues and it asked the manager what other improvements, if any, they planned to make as a result of the visit. The manager confirmed that the service manager now carries out all visits under Regulation 26 and that they are no longer done by the home managers. We looked at a random sample of safety certificates and we found that they were all in place and up to date. The home has a fire risk assessment that was reviewed on 29/09/08 and fire drills take place on a monthly basis and the records showed that the last one was held on 15/06/09. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 25 38a Woolifers Avenue DS0000018119.V376768.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 YA22 Good Practice Recommendations It is recommended that the manager adds the contact details and the role of the Care Quality Commission to all versions of its complaints procedures to ensure that people know who regulates the service. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 26 Care Quality Commission 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 38a Woolifers Avenue DS0000018119.V376768.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!