Care Home: 55 The Causeway

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What the care home does well The staff understood the importance of gaining information and assessing prospective residents before offering them a place at the home. On the whole information and documentation designed for the people using the service was in a suitable format. The home offers a homely place for residents to live and is very welcoming to visitors. People had been able to make choices about the decoration within the home. Each care plan included risk assessments, which were kept under review. The management of risks addressed safety while aiming to improve outcomes for people. The manager acted as an advocate for the residents. For example she was currently pursing why a routine health check had been cancelled by the GP surgery because they did not consider it necessary for a person with a learning disability. There were consistently enough staff available to meet the needs of the people using the service. Safe recruitment practices ensured people using the service were kept safe. People using the service and their visitors were aware of how to make a complaint. What has improved since the last inspection? There had been a number of improvements since the last inspection. It is an indication of the quality of leadership that these changes have progressed and the outcomes for people have improved. The improvements include: Detailed written plans for all aspects of care. Service users being supported to take appropriate risks. The home being more comfortable and homely. Resident had chosen the furniture and fittings for the communal areas. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Staff now have the opportunity to discuss work, personal issues and training needs during supervision sessions. What the care home could do better: The staff must ensure that medications carried forward from one month to the next are counted and recorded when new stocks arrive at the home. The company must ensure that the manager becomes the registered manager of the home. The contract between the resident and Fremantle should be in a format suitable for the resident to understand. There should be more recorded evidence as to how people using the service have made decisions, and how their plans of care have been agreed, for example, their reaction to being told about a proposed outing. Staff should continue to consider ways in which service users can be stimulated and take part in even more meaningful activities inside and outside the home. Consideration should be given to more frequent team meetings, especially the rescheduling of meetings that need to be cancelled. Key inspection report CARE HOME ADULTS 18-65 55 The Causeway Carlton Bedfordshire MK43 7LU Lead Inspector Sally Snelson Key Unannounced Inspection 2nd September 2009 09:30 55 The Causeway DS0000071557.V377268.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. 55 The Causeway DS0000071557.V377268.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 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 55 The Causeway Address Carlton Bedfordshire MK43 7LU 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) 01234 720246 The Fremantle Trust Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Learning Disability - Code LD The maximum number of service users who can be accommodated is: 6 13th October 2008 2. Date of last inspection Brief Description of the Service: 55 The Causeway is a residential care home for up to six adults with learning disabilities managed by the Fremantle Trust in conjunction with Bedfordshire Pilgrims Housing Association (BPHA), who are responsible for the maintenance and upkeep of the building. The home is a large bungalow situated in the rural village of Carlton, approximately eight miles north of Bedford Town Centre. The accommodation comprises of six single bedrooms, two lounge/diners, sensory room, activity room, laundry, kitchen, bathing and toilet facilities and a staff office. The home has a substantial garden and parking for several cars to the rear of the building, accessible through locked gates. The home has developed some user-friendly information for current and prospective service users. 55 The Causeway DS0000071557.V377268.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 star. This means the people who use this service experience good quality outcomes. Up until 1st March 2008 55 The Causeway, a home for up to six adults with learning disabilities, was managed by Bedfordshire and Luton Partnership NHS Trust (BLPT). Fremantle now runs it in conjunction with Bedfordshire Pilgrims Housing Association - who are responsible for the maintenance of the building. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for younger adults that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection was a key inspection, was unannounced and took place from 09.35am on 2nd September 2009. As the manager Jo Gray was away from the home doing training a second date of 8th September was arranged to look at staff files and feedback to the manager and Liz Harris, the operational manager. During the inspection the care of three people who used the service (residents) was case tracked. This involved reading their records and comparing what was documented to what was provided. Also sampled during the inspection were staff files, health and safety records and other documents relating to the provision of care. An expert by experience joined the inspection from 12.30hrs to 14.30hrs. Experts by experience are: People who are currently using social care services People who have previously used social care services People who may require but do not receive social care services because the services offered are inappropriate, (i.e. culturally), or they are not offered services, (i.e. asylum seekers) People who are living with or caring for a person who uses social care services. The report provided by the expert was used to inform decisions about this report. In addition people who lived at the home were observed for their reaction to situations and staff were spoken to and their opinions sought. Any 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 6 comments received about the home, plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: What has improved since the last inspection? There had been a number of improvements since the last inspection. It is an indication of the quality of leadership that these changes have progressed and the outcomes for people have improved. The improvements include: ● Detailed written plans for all aspects of care. ● Service users being supported to take appropriate risks. ● The home being more comfortable and homely. Resident had chosen the furniture and fittings for the communal areas. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 7 ● Staff now have the opportunity to discuss work, personal issues and training needs during supervision sessions. 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. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 The staff understood the importance of gaining information and assessing prospective residents before offering them a place at the home. This ensured that staff were sure that care needs could be met. 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: There was a Statement of Purpose and a Service Users Guide. These documents had all the required information; although they did refer to the manager as the registered manager when she had yet to complete the registration process. The documents had been produced in a pictorial format, which staff believed would be suitable for the residents. There had not been any new admission to the home since the last inspection. However at the last inspection we reviewed how an admission process was undertaken. At this inspection we saw a letter praising the staff for the manner in which this transition had been dealt with. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 10 Residents had contracts between themselves and the housing association, and between them and the home. The contract for the housing association was in pictorial format, but the one for Frematle was in normal text. The manager was aware of the need to translate this document and to ensure that information about the cost of a resident using the home’s transport was included. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Each care plan included risk assessments, which were kept under review. The management of risks addressed safety while aiming to improve outcomes for people. 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: It was apparent that since the last inspection staff had worked to ensure that care plans were person centred and included information about all the care that staff provided. The majority of the plans had been rewritten since the last inspection, although it was not always apparent exactly when. Throughout the plans there was evidence that staff were reviewing the care provided, changing instructions in the care plan and signing and dating these changes as evidence of regular reviews. The plans would benefit from some indication of 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 12 agreement. For example evidence that staff had read the plan to the resident and they had shown their agreement as documented in their communication diaries, or have the agreement of a next of kin or advocate. The new plans showed that staff were looking at outcomes for people and were aware of the need to move them forward, even when this was very slow. The new support plans superseded other information in the files, but because previous information had not been removed, it could be confusing for new staff, who might not read the most current instructions first. The manager told us that she had not archived the previous information as she wanted to demonstrate to us the improvements made to the documentation since the last inspection. We are therefore confident that this will be rectified very soon. Staff were involving residents in decision making. For example weekly they planned menus and created the necessary shopping lists. They were also asked if they would like to join in different planned activities and staff were able to talk about how they identified a positive or a negative response. Again the plan did not clearly indicate decision making processes. For example statements like, ‘I would like manager to go to the bank and withdraw money out on my behalf. Occasionally I would like to go to the bank,’ needed to show how staff had come to this conclusion, so as not compromise the manager. The expert by experience spent a lot of time talking to staff about how they provided support and care for the resident and it was apparent that people were helped by staff to make choices as often as possible. One resident was planning a party and the food was to be her choice. Risk assessments were in place to support various activities. In the past the risk assessments had been very generic and did not identify how risk should be managed. This had now been addressed and as a consequence people living at the home were being supported to routinely take risks. For example boil kettles, and help make meals. Risk assessments also indicated why certain restrictions, such as a locked gate were necessary. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16,17 Staff were supporting people to experience a range of activities both inside and outside the home, including the domestic routines of the home. More work was needed to show how residents were consulted about their lifestyle. The home recognised this and planned to make some changes People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There was an individual plan for activities for each person in the home for each day. There had been a great improvement in the way staff recorded how people responded to activities. It still appeared that some people had very little to stimulate them. For example the plan for the week for one resident who moved around the house with the ease was: 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 14 17th Tidy bedroom, day centre 18th Laundry 19th Household chores, puzzles 20th Walk to playing field 21st Day centre, church These activities would not provide much stimulation and would certainly not fill much of the day, every day. Staff told us that other activities were introduced as people indicated that they would like to do something. On the day we returned to give the feed-back two of the residents and two staff were having a day out in London. There were plans for Fremantle to open a day unit that would be accessible to residents from all the local homes and allow them to participate in a variety of activities on a sessional basis. We believed that this would help improve the outcomes for people in this area of their care. Staff told us that there had been two pubs in the village and the larger one, which had been accessible to residents, had recently closed. The second pub had installed a ramp to allow access to all and some of the residents enjoyed an outing to the pub early evening when it was not too busy. One of the residents had chosen the theme for a Barbecue to be held in the next few weeks, to which friends and family could be invited. Throughout the inspection staff knocked and doors of bedrooms and bathrooms for permission to enter. Many of the residents had their own routines, and although on the whole they had their meals at the same time they could eat when they wanted. The main meal was in the evening. People had their breakfast when they got up and wanted it. At lunchtime we noted some residents had bread and butter and baked beans and other sandwiches of their choice. Throughout the inspection we witnessed people making drinks as and when they wanted. Weight records suggested people were eating the correct amount of food to maintain their weight. Residents worked together to create a menu for the following week. This was done using picture cards and recipe books. Each person had the responsibility for one day of the week and as a group they chose what meat they would have on a Sunday. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The home ensured that residents had access to healthcare; they were encouraged to be independent and supported to attend regular appointments and visit local health care services. 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: All of the people using the service needed some degree of support with their care and health needs. Staff were keen to support the residents to attend well persons clinics and to make healthy lifestyle choices. The manager was currently pursing why a routine health check had been cancelled by the GP surgery because they did not consider it necessary for a person with a learning disability. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 16 The home had recently changed the pharmacy provider, and were experiencing the usual teething problems of understanding new charts, and getting supplies delivered at the correct time. We were disappointed that at this inspection we were unable to reconcile all of medications as some of the ‘unused’ medications had not been carried forward. Staff were unfamiliar with the new Medication Administration Records (MAR) and were not completing a task they had been routinely doing. This was identified and addressed immediately and would be fully compliant in time for the next delivery. All but one of the residents had a medication cupboard in the bedroom. Individual medication files detailed exactly what medication a resident took, why they took it and how they were to be given it. As reported previously, because staff had undertaken Non-Aggressive Physical and Psychological Intervention (NAPPI) training, so as to not have the need to use restraint on residents, the use of ‘as required medication’ had decreased significantly and we noticed a major change to people energy levels and general interest. The decrease in some medications had also impacted on peoples desire to do more with their time and leave the home. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The service had a clear easy to understand complaints procedure that was in formats to help anyone living at, or involved with, the service to complain. People were also encouraged to make suggestions for improvement. 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: There was a complaints procedure available for the residents and for people having connections with the home. The procedure was detailed and informed the complainant when they could expect an outcome. It was in pictorial format as part of the Service Users Guide. There had been no complaints made to, or about, the home since the last inspection and we had not had a complaint made to us. Staff were able to talk to us about their understanding of safeguarding vulnerable adults (SOVA) and when it would be necessary to inform the local authority SOVA team. Training plans indicated that staff had been trained in SOVA and that a record was kept of when any training needed to be updated. We looked at the record of the money held on behalf of residents. These were all correct and tallied with the receipts kept. Staff encouraged the residents to keep small amounts of money for themselves to spend as they wished and 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 18 there was evidence that one resident had improved her understanding of money and could work out how much she needed to take to the shops if she was buying clothes and how much she needed for a packet of crisps for example. As already stated we were concerned, that how transport costs were calculated and divided was yet to be included in residents’ contracts. We had seen this information in other Fremantle homes so we were aware of the policy. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 There has been some consultation with residents about the décor, especially for their own rooms. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the inspection we and the expert by experience with his supporter undertook an informal tour of the home. Since the last inspection the home had been decorated and a ‘Snoezelum’ room re-established as a relaxation area. The home was clean and tidy, but it was disappointing to see that much of the new paintwork had flaked. We were told it was going to be necessary to repaint some areas as the flaking had not been caused because the wrong paint had been used and not because of damage. We were therefore 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 20 disappointed that this was delayed. We were aware that this was the responsibility of the housing association and saw how the manager was ensuring it would be done. We were pleased to see that resident had chosen the furniture and fittings for the communal areas, and that each resident had a comfortable chair of their choice. There were a variety of ornaments and photographs and pictures around the home. Since the last inspection the front garden had been made secure, so that people could spend time in the front of the house and interact with the people from the village and be safe. People, who at the last inspection were denied access to the kitchen and laundry, were now using these areas appropriately with supervision. There was a bolt on the door of the small lounge. The manager told us that if residents wanted to ensure privacy at a review or during a key working session this could be used otherwise all areas of the home were open to all. The home had been partially adapted to meet the needs of two of the residents with visual difficulties, but was not wholly appropriate for people with these needs. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 There were consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. Safe recruitment practices ensured people using the service were kept safe. 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: There were at least three staff on duty at all times during the day not including the manager. For the last few months the home had used one waking and one sleeping member of staff at night instead of two waking. This new practise had been reviewed and evaluated and this policy was now operational. The off-duty ensured that there was always a staff member on duty who could administer first aid, administer medication and drive the transport. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 22 We looked at the personnel files of four members of staff. We were satisfied that the home had obtained all the information needed before staff started working at the home, such as a Criminal Record Bureau (CRB) check, two written references and any home office paperwork. Staff files indicated that staff had been trained in all the ‘mandatory’ topics, such as moving and handling, infection control, food hygiene, first aid, fire safety, health and safety and safeguarding. The manager had a record of the training undertaken, when it was to be updated and any training opportunities available. The staff files we looked at had evidence, in the form of certificates, that staff had undertaken all these courses. There was also evidence that all staff undertook thorough induction training when they first started work at the home. Staff said they have a number of training opportunities and get regular supervision from the manager. Staff meetings were held but would benefit from being more regular. The home was reducing its use of agency staff, but there was still some reliance. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities 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 were disappointed that the manager, Jo Gray, who had the necessary qualifications and experience to become the registered manager, had yet to complete the registration process. However we had received an incomplete application so we were confident that the process was underway. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 24 The manager was not on duty on the day we inspected. However, a carer ably assisted us with the inspection. The manager and the staff team had worked hard since out last inspection to improve the service offered to the people who live in Carlton. It was an indication of the quality of leadership that these changes had progressed and the outcomes for people had improved. The manager was aware that she did not always have the written evidence to support what was being done, as she concentrated on outcomes. There was a system in place to monitor the quality of the service provided. As some of the people who lived at 55 the Causeway were unable to communicate verbally, the manager had written to families, advocates and professionals who visited the home, to ask their views on the service provided. The findings were very positive and were used to plan future care and support. Quality was assured by the provider’s representative visiting monthly (as required by regulation 26) and making a report of the visit. The operational manager had recently audited the home and its management. The manager had also asked staff to take a regulation and look at the impact of it on the home. It was apparent that staff had an insight into regulation and outcomes for people. We looked at the log book in which staff record when they have done tests of the fire alarm and emergency lighting systems. Tests had all been carried out as required. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 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 3 2 X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 x x 3 x Version 5.2 Page 26 55 The Causeway DS0000071557.V377268.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Staff must ensure they dispose of, or document that they carry forward, any unused medication. This had been identified and was dealt with immediately. Timescale for action 01/10/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3. Refer to Standard YA5 YA7 YA12 Good Practice Recommendations The contract between the resident and Fremantle should be in a format suitable for the resident to understand. There should be more recorded evidence as to how people using the service have made decisions, and how their plans of care have been agreed. Staff should continue to consider ways in which service users can be stimulated and take part in even more meaningful activities inside and outside the home. Consideration should be given to more frequent team DS0000071557.V377268.R01.S.doc Version 5.2 Page 27 4. YA36 55 The Causeway meetings. 55 The Causeway DS0000071557.V377268.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. 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