Care Home: 49 Adshead Road

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What the care home does well There is a good atmosphere in the home and both the people using the service and a relative said that it is ‘homely and friendly’ and that they ‘always feel at home and welcome’. The process of admission is good, all people who would like to use this service are given the opportunity to visit and spend time at the home before deciding if they want to be admitted. All people at the home have the opportunity to go on holiday each year to a place of their choice; this is paid for by the service. The meals are decided in meetings with the people who live at the home, and some people are able to use the kitchen depending on safety. Visitors are welcome and can visit at any time, a relative told us ‘We are always made welcome, and the staff understand us’ 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 The administration of medication is good; each person gets their medication as prescribed by the doctor. Each person is able to participate in a variety of activities that they like, some people use day services and other have activities at the home or at other venues. There is a complaints process and this is available in the home and in the Service Users Guide which is in audio and written format so that those who find reading difficult can have access to this document. The process of employing staff ensures that they are safe to work with vulnerable people. There is a low turn over of staff which means that they know the people who use the service well. What has improved since the last inspection? This is a service that has been newly registered as a Limited Company, but has been a care service for about 15 years. Previous reports have indicated that this is a good service that offers excellent quality and maintains the safety of those who live and work there. What the care home could do better: The storage of medication did not meet current legislation, the provider immediately ordered the appropriate storage and has had this fitted. The records for people using the service are not kept together and this makes it difficult to assess if all the care given is appropriate and working. It is recommended that an audit is done and changes made where appropriate. The daily records detailing what each person is doing and how they are is very limited. This would make re-assessment and auditing difficult. It is recommended that the daily records reflect the care given and the activities that people are participating in with the outcomes. Key inspection report CARE HOME ADULTS 18-65 49 Adshead Road 49 Adshead Road Dudley West Midlands DY2 8ST Lead Inspector Mrs Debbie Widdowson Key Unannounced Inspection 11th November 2009 09:00 49 Adshead Road DS0000073214.V377993.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. 49 Adshead Road DS0000073214.V377993.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 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service 49 Adshead Road Address 49 Adshead Road Dudley West Midlands DY2 8ST 01384 240502 01384 240507 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) Grazebrook Homes Ltd Mr Zaffar Iqbal Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 49 Adshead Road DS0000073214.V377993.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) 9 The maximum number of service users to be accommodated is 9. 2. Date of last inspection New service Brief Description of the Service: 49 Adshed Road is a small service for people with learning disabilities. It is an established service that has been running for about 15 years and has recently changed from a single owner to a limited company. The large house is in a residential area and is suited to those who live there; it is close to Dudley town centre and is served by a local bus route. There is a parking space and gardens to the rear of the house, this is used in the summer and each person is encouraged to enjoy the outside space. The fees may vary and prospective people are asked to contact the provider for up to date information. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This service has been rated as a 2 star service. This means that people using this service have good outcomes in care and provision. This was an unannounced visit, which means that the provider did not know that we were coming. The visit was undertaken to establish if the service is run to the best interest of those who live there and offers a good quality and safe service. Prior to the visit we looked at a variety of records such as any concerns or complaints, notification made by the home, third party feedback from other professionals and the Annual Quality Assurance Assessment [AQAA] form that was completed by the manager. These documents assist us in making the final judgement of this service. While at the service we looked in depth at 2 people’s records and spoke to the manager, staff and one person about the care that they receive. We also looked at process to ensure the quality and safety of each person. We read three staffing records to assure us that the process of employment is safe and ensures that staff are suitable to work with vulnerable adults. Management of medication and risks in the home we examined to ensure these are appropriate and safe. A review at 39 Adshed Road, the sister unit, was inspected on the same day. What the service does well: There is a good atmosphere in the home and both the people using the service and a relative said that it is ‘homely and friendly’ and that they ‘always feel at home and welcome’. The process of admission is good, all people who would like to use this service are given the opportunity to visit and spend time at the home before deciding if they want to be admitted. All people at the home have the opportunity to go on holiday each year to a place of their choice; this is paid for by the service. The meals are decided in meetings with the people who live at the home, and some people are able to use the kitchen depending on safety. Visitors are welcome and can visit at any time, a relative told us ‘We are always made welcome, and the staff understand us’ 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 6 The administration of medication is good; each person gets their medication as prescribed by the doctor. Each person is able to participate in a variety of activities that they like, some people use day services and other have activities at the home or at other venues. There is a complaints process and this is available in the home and in the Service Users Guide which is in audio and written format so that those who find reading difficult can have access to this document. The process of employing staff ensures that they are safe to work with vulnerable people. There is a low turn over of staff which means that they know the people who use the service well. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 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 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 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): Standards 1 and 2 were looked at 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. Each person can be assured that their individual needs would be assessed before admission to ensure these can be met in a way that suits them. EVIDENCE: The last person to be admitted to the home was three years ago. The process for admission is clear and assures us that any person wishing to use this service would have a full assessment with regular review and have time to visit the service and spend time in the home with other people who live. After this a joint decision is made as to whether the home is right for them and that their needs can be met. Records of previous admission show that this is the process used for past admissions. Each person is reviewed at regular intervals after admission to ensure that the placement is working and continues to meet their needs. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 9 There is a Statement of Purpose was last reviewed in 2004. It states what the service offers and who works there. There is also a Service Users Guide which is written and audio format; this also contains the complaints process. In the two files we reviewed, both residents had a contract which had been signed by person. 49 Adshead Road DS0000073214.V377993.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): Standards 6, 7 and 9 were looked at. 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. Each person can be assured that their needs are met and they are supported to take appropriate risks. EVIDENCE: Two people were ‘case tracked’; this involves reading their records, checking assessments, discussing their care with staff, the person and their relatives where appropriate. It was noted that the format for recording the care and assistance needed is being changed; the new process shows clearly what is needed and how assistance should be given. The daily “diary” records completed by staff are 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 11 not reflective of these plans and do not record the daily activities, assistance given or any incidents or changes in behaviour or activity. There are risk assessments available, these are kept with the environmental risk assessments and are not easily found, the provider should assess this and change the system if needed to ensure that access for each person is easier. The care give and assistance is good, the staff know each person very well and the people living at the home know the staff. From observation and discussion it was confirmed that each person’s needs are met and that the outcomes are good. Each person is consulted about their daily lives where this is possible, one person told us ‘I like to go out, sometimes I fall but we have agreed that this is my risk and I am happy about this’. The records and personal information are kept in a locked area and only staff and professional have access to these. In one profile looked at the person had signed the plans of care to show that they had been involved, they told us ‘I know what care I am going to get because we talk about it’. 49 Adshead Road DS0000073214.V377993.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: Standards 12, 13, 15, 16 and 17 were looked at 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. Each person can be assured that there are opportunities for development and that they will be supported to enjoy a social life and maintain contact with family and friends. EVIDENCE: There is information to show the activities of the 2 people case tracked. Two people use the day centre, and the remaining people at the home are involved in activities at the home and in the community. No one has employment. There are a range of activities such as Crafts, organised games 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 13 and gardening in the summer. On the day of the visit, there were 5 people at home they were all in the lounge watching TV. Each person has a diary and all activities are recorded in there. The kitchen is modern and there are secure cupboards where chemicals are stored. Risk assessment has been completed. All residents are encouraged to participate in cooking and preparing food. The menus and daily food are decided on a week by week basis and there is room for people to change their minds if they wish. The home is positioned close to Dudley town centre. There is a frequent bus service which people use. There is a park across the road from the home that people use for a walk or to play. There is regular attendance to evening clubs such as Horizons on Friday night once a month and Gateway is weekly on Tuesdays. People can choose to go, but the manager stated that most people do go to the Horizon club. A mini bus and people carrier are shared between the 39 and 49 Adshed Road. The home provides holidays for people and they are involved in choosing where they want to go. They have been to Disneyland Paris, and Monaco in the past but the residents prefer holiday camps in UK. The service normally takes 4 to 5 people from each home so can mix together, which is what they like. The service pays for travel, accommodation and meals; each person only needs to supply their own spending money. Holiday choices are discussed at residents meeting. Families can visit when they like, and there is an open door policy. Staff will take people out to see their family particularly if it is not possible for them to come to the home. Residents can invite friends over and have friends at other homes. At this time there are no intimate relationships, we were assured that staff know how to deal with this issue but have not had formal training; it is recommended that the provider considers this. 49 Adshead Road DS0000073214.V377993.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): Standards 18, 19 and 20 were looked at 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. Each person can be assured that their needs will be met a way they prefer and that the medication management and administration is good. EVIDENCE: Each person has a record of visits to the GP and other professionals. A dental service visit the home every six months, if there is a need to see the dentist before this date an appointment can be made. The optician comes once a year to visit and check each person visions, the prescriptions are delivered to the home. The staff and management are active at making appointments to see other professionals where needed. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 15 Chiropody can be done at the day centre and each person can also have this done at the home, there is both a private and NHS funded Chiropody service available. Medication Administration Records [MARs] are completed appropriately and all medication is accounted for at the beginning of the 28 day cycle. A Medicine Dispensing System [MDS] is used. Staff have received training in medication administration and management. There are no controlled drugs used at this time. Medication is stored in a unlocked filing cabinet in the corner of the lounge area. This does not comply with the Medicines Act and is inappropriate. The provider was informed that a cabinet that meets the regulations needs to be made available. The provider informed us the day following the visit that an appropriate cupboard had been purchased and would be fitted on arrival. The process of medication administration needs to be looked at to ensure that in the case of an emergency the medication can be stored safely. The MARs are filled in correctly and a record of the numbers of medication arriving at the home is recorded. There are no homely medications. Each person has their medicines assessed each year at the yearly medical check. There is a staff list of names and initials/signatures for staff who administer medication, it is important that this is kept up to date. Each person’s care plan states what is needed to assist them, there is evidence that this is shared with the person, and in one case the plan was signed. 49 Adshead Road DS0000073214.V377993.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): Standards 22 and 23 were looked at. 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. Each person can be assured that their concerns and complaints will be listened to and acted upon. Each person can also be assured that they are protected from harm through the understanding and knowledge of the staff. EVIDENCE: This service has had no complaints. A member of staff told us that they tend to deal with any “grumbles” straight away, before it escalates to a formal complaint. Staff feel they have good relationships with people and their relatives so there have not been any real issues to deal with. There is a clear policy for the management of complaints and staff are fully aware of their roles and responsibilities in dealing with concerns and complaints in relation to the service and people whom live there. All staff are aware of their role in maintaining the safety of each person and know that any allegation, suspicion or witnessed abuse is dealt with according to the Local Safeguarding Strategies and the home’s policies. The home uses Dudley Metropolitan Borough Council’s Adult Safeguarding Policy; a copy was available in the office. The home has not made any 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 17 safeguarding referrals. The registered manager has completed the management level adult protection training programme and staff have completed safe guarding training. The registered manager has also completed training in Depravation of Liberty Safeguarding [DOLs]. No orders for DOLs are in place for any person at the time of this visit. The home uses the Primary Care Trust policy in relation to DOLs, which includes a flowchart for assessing capacity. The registered manager said if there was any issue he would refer it to the social worker immediately. He recognises that it would need to be a multi-disciplinary decision. Some staff have been on training, and social services are organising further training and it has been agreed that more staff will be attending this. In addition the registered manager has done some awareness training with senior care staff. Staff meetings are held regularly where the registered manager can up date staff on issues. 49 Adshead Road DS0000073214.V377993.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): Standards 24 and 30 were looked at. 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. Each person can be assured that they live in a homely, comfortable and safe environment that is clean and hygienic. EVIDENCE: It was noted that there is a homely environment that is clean and maintained to a safe standard. There is a large outside area at the back of the home which can be accessed through the kitchen and patio doors in the lounge. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 19 Bedrooms are personalised with the items of each person and staff are aware of the needs of each person and consult them when things change. The bathrooms have showers and baths which means that people can choose how they are bathed and assisted. The bathrooms are of a reasonable size and suitable. The downstairs bathroom needs some remedial work to ensure that it is of a good standard of décor and can be kept clean. The communal areas are of a good size and furnished in a comfortable and homely way. The laundry has one machine and two tumble driers. One person said stated that she was happy at the home and would not want to move. 49 Adshead Road DS0000073214.V377993.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): Standards 32, 34, 35 and 36 were looked at. 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. Each person can be assured that their needs are met by staff who are well trained and are safe to work with vulnerable people. EVIDENCE: Two staff records were looked at, this assured us that all checks are made before employment to ensure that they are suitable to work with vulnerable people. There is a small turn over of staff and this ensures that there is consistency in the care and assistance provided to each person using this service. There is a full induction into the home for all new staff telling them how the home runs and the people who use this service. All employed staff as part of their contract must do both the Learning Disability Qualification and a least the National Vocational Qualification at level 2. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 21 All staff have completed or commenced the National Vocational Qualification at level 2 and a further two staff have started their NVQ level 3 and a further two staff have commenced NVQ level 3. This shows that staff are suitably trained to meet the needs of the people they care for. One person has also completed the Learning Disability Qualification. Training records for staff show that mandatory training is up to date and/or planned. Staff have also had training in epilepsy, infection control, bi-polar disorders, dementia and medication administration and management. Supervision agreements have been signed by the staff at the beginning of their supervision and the records show that each member of staff has regular supervision to discuss work progress, learning and issues related to care. The registered manager ensures that staff do not work excessive hours and that they have sufficient rest days. The duty roster confirmed that staff work 8 hour shifts covering the morning, afternoon and night. There are no split shifts and staff working during the day do not work at night. During the night the registered manager is available in the event of an emergency. Managers work flexibly with staff to minimise the use of agency, can usually find cover for sickness and absences by working flexibly. 49 Adshead Road DS0000073214.V377993.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): Standards 37, 39 and 42 were looked at 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. Each person can be assured that the home is run in their best interest and that it is safe and suitable to live in. EVIDENCE: The registered managers for number 39 and 49 Adshed Road work across both homes, providing cover for each other as needed but managing the homes independently. Both managers have completed the Registered Managers Award in 2007. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 23 Service records show that the appliances are tested yearly. Records looked at confirmed that this is done and that repairs and/or replacement of equipment and furnishing is done promptly. A quality assurance system is in place, and is provided by Mercia Care. This is a self assessment process designed to help the home assess their own services against National Minimum Standards and make necessary changes. This has partly been completed and we were told that action plans will then be developed to improve the service further. The home has surveyed relatives and people living at both 39 and 49 Adshed Road, these have not yet been analysed. A relative told us ‘I am happy with this service and they always ask me if everything is OK’. They also said that ‘the staff are polite and professional and we never have any bother’. A person using the service said ‘I like it here’. There are regular meetings for people using the service and staff to ensure that information is shared and that all people in the service are consulted and are involved in decision making. 49 Adshead Road DS0000073214.V377993.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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Version 5.3 Page 25 49 Adshead Road DS0000073214.V377993.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 2 Refer to Standard YA6 YA41 Good Practice Recommendations It is recommended that each persons file is assessed and that information relating to this person is easily accessed. It is recommended that an audit is carried out on the quality of the daily records for each person and actions are put into place to improve these in accordance with standards. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 Page 26 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. 49 Adshead Road DS0000073214.V377993.R01.S.doc Version 5.3 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!