Care Home: 59 Hatherley Road

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What the care home does well Care plans provide staff with detailed information about meeting peoples needs and this helps to ensure that peoples needs are met consistently. The activities completed by people in the home are led by their needs and records show that they lead varied and active lives with staff support was required. All 3 of the people in the home are encouraged to take an active role in the day to day running of the home being made responsible for completing a number of chores. Records of income and expenditure for people in the home are thorough and minimises potential risks to people. People live in a comfortable and well maintained environment that meets their current needs. Regular health and safety checks completed by the staff minimise potential risks to people. Staff recruitment procedures are robust and minimise the potential risks to people in the home. Staff receive training to meet the needs of the people they support and maintain a safe environment. What has improved since the last inspection? The home has environmental risk assessments specific to the service rather than generic assessments. Peoples care plans provide staff with a greater level of detail. A comments page has been introduced to enable visitors to comment on what they find. The management of peoples medication has improved and this minimises potential risks to people in the home. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 What the care home could do better: Peoples care plans could promote learning new skills, rather than maintaining current skills. More could be done by the staff team to promote choice and independence around the food and meals available in the home. PCP`s could be introduced that highlight goals people want to achieve, their wishes and other information important to them. Key inspection report CARE HOME ADULTS 18-65 59 Hatherley Road 59 Hatherley Road Gloucester Glos GL1 5LB Lead Inspector Mr Paul Chapman Key Unannounced Inspection 23rd July 2009 09:00 59 Hatherley Road DS0000067434.V376745.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. 59 Hatherley Road DS0000067434.V376745.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 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 59 Hatherley Road Address 59 Hatherley Road Gloucester Glos GL1 5LB 01452 537633 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.holmleigh-care.co.uk Holmleigh Care Homes Ltd Lindsey Marie Riley Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. For one named service user over the age of 65 to reside at the home. Date of last inspection 6th August 2008 Brief Description of the Service: The home is registered to provide accommodation for up to 3 people with learning disabilities. It is a terraced property that has been adapted to provide registered accommodation. Communal accommodation is provided on the ground floor with a lounge, dining room and kitchen. Upstairs are 3 single bedrooms and a bathroom. To the rear of the home is a flat, secure garden with some well maintained flowerbeds and a pond. To enable people to access facilities the service users have access to a car. Fees to live in the home are dependant on peoples assessed needs. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Before completing the inspection site visit to this service we (the CQC) sent the ex-acting manager questionnaires to distribute to people living in the home and for staff to complete. In addition to questionnaires the manager also completed an AQAA (Annual Quality Assurance Assessment). This document asks a service provider/registered manager to rate the services performance against the National Minimum Standards (NMS). A service provider/registered manager will be asked to provide evidence of what the service does well, what has improved in the past 12 months and their planned improvements for the next 12 months. What the service provider/registered manager tells us in this document helps to form a hypothesis and focus on different areas depending on what the AQAA tells us. In addition to providing evidence about how the home meets the NMS it also provides us with a Dataset (information about staffing, health and safety, complaints, the environment, policies and procedures and the people living in the home). Unfortunately we did not receive the AQAA before the site visit was completed (the acting manager provided a copy at the site visit) but we did receive questionnaires completed by 2 people living in the home, 4 staff and a GP involved with the service. The site visit was completed over 1 day in July and the acting manager was present through the majority of the visit. On arrival we were greeted by one of the people living in the home opening the front door to us. We spoke to 2 of the 3 people living in the home about their care and what it was like to live in the home. Both people were very positive about the service they receive. Once the acting manager had arrived we examined the care of the 2 people we had spoken to in depth. We looked at their needs assessments, care plans, risk assessments, the activities they completed regularly, family involvement and financial management. In addition to the records identified above we also examined documents relating to the recruitment and training of staff, quality assurance, health and safety and we completed a tour of the premises. 2 people living in the home showed us their bedrooms. Before leaving the home we interviewed a member of staff. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has environmental risk assessments specific to the service rather than generic assessments. Peoples care plans provide staff with a greater level of detail. A comments page has been introduced to enable visitors to comment on what they find. The management of peoples medication has improved and this minimises potential risks to people in the home. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 7 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. 59 Hatherley Road DS0000067434.V376745.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 59 Hatherley Road DS0000067434.V376745.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): 1,2,3,5 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. Before a person is admitted to the service they are thoroughly assessed and this minimises the risk of a person being admitted to the service whose needs cannot be met. EVIDENCE: Since the previous inspection was completed a new person has been admitted to the home. We spoke to them when we arrived. They explained that although they had been living in the home for 2 weeks they did not know the home had a complaints procedure. The acting manager stated that they will implement a Service User’s guide that includes a complaints procedure. They will also speak to the person who has moved in and explain the home’s complaints procedure. The home has a referral and admissions policy, this was reviewed by the previous manager in January this year. We examined the admission/assessment process completed by the ex-manager before the person was admitted to the home. This showed that a thorough needs 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 10 assessment was been completed with the person and their carers/social worker. There was no community care assessment and the acting manager agreed that there should have been one. Before the person moved in they visited the home on a couple of occasions, they told us this had been really good and had helped them to decide whether they wanted to move in. The person who had recently moved in did not yet have a statement of terms and conditions as they were still in their trial period. Looking at another person’s file it contained a signed statement of terms and conditions. 59 Hatherley Road DS0000067434.V376745.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 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. Each of the people living in the home has a range of care plans that provide a good level of detail enabling staff to meet people’s needs consistently. People are able to make choices about what they would like to do. Risk assessments enable people to take acceptable risks while going about their day to day lives. EVIDENCE: A requirement of the previous inspection report was that care plans required a greater level of detail to enable staff to meet people’s needs consistently. We examined the care packages for 2 people including the person that was admitted 2 weeks ago. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 12 Looking at this person’s documentation to date it showed that staff had written small number of care plans to meet the person’s assessed needs, and the person had signed them to confirm they had seen them. Looking at these documents showed that the care plans should be reviewed to ensure they contain enough detail. The other person whose records we examined has lived in the home for a number of years. Examining their records showed that they had a wide range of care plans in place to mete their assessed needs. These had been written in detail enabling staff to meet people’s needs consistently. It was difficult to confirm that the person’s current needs were being met as the care plans we examined were in need of review. It becomes a requirement of this inspection report that care plans are reviewed regularly. From reading care plans we felt that there was a focus on maintaining skills and it is recommended that when the care plans are reviewed staff should also bear in mind how people can be supported to learn new skills. From examining care plans, other records available in people’s files and daily notes it is clear that people are given choices in their day to day lives. Examples of this include what activities they take part in, which staff support them with activities and the food they choose. A good practice seen to be maintained by staff is that where an activity or choice is offered they record it even if a person refuses it. A questionnaire completed by 1 of the people in the home states that they always make decisions about what they do each day. Along with the acting manager and staff we were unable to find PCPs (Person Centred Plans) for either person. The AQAA completed by the ex-acting manager states that an aim for the coming 12 months was to build on the “listen to me” books and create detailed PCP’s. The now acting manager said that they would implement a new PCP with each of the 3 people in the home. This becomes a recommendation of this inspection report. Risks assessments were seen for both people. The assessments we saw covered a wide range of topics and minimised the potential risks to people. 59 Hatherley Road DS0000067434.V376745.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, 14, 15, 16, 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home lead active and varied lifestyles supported by the staff as required. EVIDENCE: Staff complete activity sheets for each of the people living in the home that detail what they have been doing. Currently people attend day services in Gloucester and Cheltenham and there were numerous examples of people going out individually with staff to complete activities. Speaking with one lady she explained they were really excited that they were going shopping with staff at the weekend. There are regular house meetings where people are given the opportunity to make suggestions about activities they would like to complete. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 14 Some of the activities people regularly complete included baking cakes, in house activities (bingo, DVD nights), completing domestic chores (cooking, washing and cleaning) and maintaining hobbies including puzzle books and tapestry. Staff supported 2 of the ladies to go to Torquay for their holiday this year. Earlier this year 1 of the ladies in the home was 70 years old and a party was held to celebrate this. We were able to see some photos of this event and speaking to the person they said it had been lovely. All 3 people have regular contact with their relatives and people are supported by staff to maintain these relationships as required. This may include helping with transport, making phone calls and writing letters and cards. Staff keep good records to show when family members have been in contact with people in the home. The home uses the safer food, better business package to minimise potential risks. Records were available to show what people eat and showed us that people eat a wide range of meals/food. Snacks are available throughout the day and we saw people helping themselves to food and drinks. One of the people that spoke to us said that they enjoy helping prepare meals with the staff. All 3 people living in the home are involved in shopping for the ingredients for their meals. When speaking with people they confirmed, “the food is nice” and “we can have something else if we don’t want what is on the menu”. We discussed the current method used to create menus/meals with the acting manager and suggested that people could be given even greater choice. As a result of this discussion the acting manager stated that they would implement a system where each person would be given the opportunity to shop for their own groceries and cook meals individually. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans to meet peoples personal care needs are written in sufficient detail to enable to staff to meet peoples needs consistently. People’s health needs are identified and staff support them to ensure they are met. Medication administration is effectively managed and this minimises the potential risks to people. EVIDENCE: A requirement of the previous inspection report related to the level of detail in care plans to meet peoples personal care needs. We examined the plans for 2 people which showed that a good level of detail was now in place. This included the plans for the person who moved in 2 weeks before this site visit. Examining documentation relating to peoples health showed that 1 person’s file contained a range of documents to address their health needs, and these 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 16 had been reviewed as required. The other file we examined was for the person that recently moved in and staff need to develop this section to ensure that the person’s health needs are met. Medication administration was examined. On the whole this is well-managed, since the previous inspection report was published the ex-acting manager notified us of 2 medication errors under Regulation 37. Examining the storage of medication we found a shortfall with 1 bottle of cough medicine not being labelled with the date it was opened. Administration records were thoroughly maintained with staff signing to confirm people have received their medication. We received a completed questionnaire from a GP involved in the home. When asked what the home do well they commented “they look after people with complex needs”. 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Potential risks to people are minimised through a robust complaints procedure and being supported by staff that have completed training in safeguarding adults. Peoples finances are safeguarded through the procedures followed to record and check peoples income and expenditure. EVIDENCE: Since the previous inspection site visit there have been 2 complaints made to the home. The AQAA stated that both of the complaints were addressed within 28 days and have been closed. The CQC has not received any complaints about the home. We checked the records of income and expenditure for 2 people. The staff and people to whom the money belonged signed all entries. Receipts for spending were also available in most cases. Monies are checked by 2 staff at least twice daily. Training records showed that staff have completed training in safeguarding adults. 59 Hatherley Road DS0000067434.V376745.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, 25, 26, 27, 28, 29, 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. The home is clean, homely and comfortable and meets the current needs of the people that live there. EVIDENCE: The standard of decoration, fixtures and fittings in this home has greatly improved over the previous 3 years. People now live in a home that is decorated to a good standard throughout and provides a high standard of fixtures and fittings. Over the past 2 years the bathroom and kitchen have been replaced and new carpets have been fitted throughout. Communal areas include a lounge/diner with a 3-piece suite and a dining table. The lounge has a digital TV, DVD player and stereo. 2 bedrooms were seen on this occasion, speaking to the owners of these rooms they confirmed that they had chosen 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 19 the colour and style of the decoration. Both people said that they really liked their bedrooms. At the time of this site visit the home was clean and tidy. The AQAA completed by the ex-acting manager states that a shortfall to address is the re-cycling and that this would have been a goal in the next 12 months. Comments from staff included, “people choose the colours of their bedrooms”, “the windows in the bathroom and kitchen should be replaced”, and “a 2nd toilet downstairs would be useful”. 59 Hatherley Road DS0000067434.V376745.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 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment process for new staff is robust and minimises the potential risks to people in the home. The organisation provides staff with the appropriate training to meet people’s needs and maintain their safety. EVIDENCE: There are comprehensive training records available for each of the staff, training needs are identified and courses are arranged to meet those needs. We spoke to a member of staff about training, they said that the organisation offer a good range of training. Since we completed the last inspection 1 new member of staff has been recruited. Examining the recruitment records showed that the process was robust and minimises potential risks to people in the home. All of the documents and evidence required by these regulations were present. The 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 21 AQAA states that people living in the home are encouraged to be involved in the interviewing of new staff. We examined a copy of the staffing rota and spoke to staff and people in the home about staffing. There was agreement that staff are always available when they are needed and the rota showed that there is always at least 1 staff member on duty at all times. A survey questionnaire completed by staff commented that “sometimes with only 1 staff member on duty it can limit the activities for people in the home”. From the completed AQAA the acting manager states that: All staff are put on a weeks induction course covering all basic courses with in the first six weeks of employment, they are then sent on an introduction into care provided by an external training provider. They are also given a copy of the GSCC book and a company employee handbook. The company has recently made a skills pledge to all staff, 1 staff member has recently started an NVQ level 3 (National Vocational Qualification), while another has commenced distance learning through Cirencester college. 59 Hatherley Road DS0000067434.V376745.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 home that has been well-managed in the past 12 months and as a result the quality of the service has improved. Health and safety around the home is taken seriously and the checks and risk assessments in place minimise the potential risks to people. EVIDENCE: 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 23 The home’s acting manager was in the process of applying registration with the CQC when they left shortly before this inspection site visit. As a result of this a manager registered with the CQC from 1 of the organisations other homes is acting manager at present. They arrived at the home shortly after us. Speaking with them they stated that the organisation has recently employed a person to become the registered manager of this service and they were due to start in the week following this site visit. The organisation must now submit an application to the CQC to register this manager. The previous acting manager has clearly worked hard to improve the quality of the service in the home We spoke to 1 staff member during the site visit; they said that they enjoyed working at the home and that they felt the service was led by the needs of the people living in the home. We asked about the activities people are regularly involved in and they confirmed the records we saw. Observations during the site visit showed friendly and respectful relationships between the staff and people living in the home. Questionnaires received from staff made comments including, “we are good at keep people active and involved in the home and it’s running”, “we provide individuals with a homely and friendly atmosphere”, “we fulfil the needs of the people in the home”. From the evidence gathered as part of this inspection site visit we would agree with these statements. From a completed questionnaire by staff they commented, “We have a very good team that knows the people living in the home well”. Under Regulation 26 of the Care Homes Regulations (2001) where a provider is not in day-to-day charge of the home monthly visits must be completed by someone from outside the home. The organisation employs someone to do this and examination of the reports they complete after each visit show they are thorough, providing detailed feedback to the acting manager and setting targets for them to achieve, there was evidence of these goals being achieved. These reports form part of the home’s quality assurance procedure. Since the previous inspection comment sheets have also been introduced for visitors to complete if they wish, we examined a sample of these which showed a number of positive comments about the service. The home has a weekly/daily cleaning checklist for staff to follow. This minimises the risk of tasks being forgotten. Each month a member of the staff team has the responsibility for completing a health and safety audit. Records showed that these had been completed regularly and covered areas including: - building and estate, equipment and facilities, kitchen and food hygiene and fire safety. In addition to this monthly audit other audits being completed included medication practice and vehicle safety. There are a number of regular checks completed by staff to minimise risks to people’s health and safety and we saw records of the following: 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 24 • • • • • • • fridge/freezer temperatures being recorded daily Fire extinguishers, smoke detectors and torches are checked weekly Hot water outlet temperatures are recorded weekly The first aid kit is checked weekly The home’s vehicle checked weekly Staff complete a visual inspection of electrical equipment around the home. Portable Appliance Testing (PAT) was completed by a qualified engineer in August 2008. Since the previous inspection a range of environmental risk assessments have been introduced that are specific to the service. This is an improvement from the previously generic risk assessments. The home has a fire risk assessment that was reviewed in March 2009. 59 Hatherley Road DS0000067434.V376745.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 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 3 15 3 16 3 17 2 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 26 59 Hatherley Road DS0000067434.V376745.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 YA6 Regulation 15, 12(3) Requirement All care plans must be reviewed at regular intervals, and at least twice yearly. Failure to review care plans at regular intervals may mean that peoples changing needs are not identified and therefore their needs are not being met. 2. YA37 8, 9 The acting manager must submit an application to the CSCI to become a registered manager. 02/10/09 Timescale for action 02/10/09 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. Refer to Standard YA2 YA6 Good Practice Recommendations Community care assessments should be obtained for all future possible admissions to the home. As well as care plans providing staff with information about DS0000067434.V376745.R01.S.doc Version 5.2 Page 27 59 Hatherley Road maintaining peoples skills they should also promote people learning new skills. 3. YA6 Each person should have a Person Centred Plan (PCP) that highlights their hopes/dreams and goals for the future. Once these are in place there should be evidence of those goals being achieved. Any future admissions to the home should receive a copy of the home’s complaints procedure. 4. YA22 59 Hatherley Road DS0000067434.V376745.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission South West 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. 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