Care Home: 60 Wood Lane

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What the care home does well From information obtained through this inspection the people who use the service can be confident that they will obtain a good standard of care and support. They will also be provided with the opportunity to continue to with their daily lives as they wish. They can be certain that their concerns will be listened to and that they will be protected from possible abuse or harm by the systems in place. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 The service provides a homely comfortable environment that is able to accommodate their present needs and has the necessary equipment to do so. Staff are friendly welcoming and supportive and have be provided with the training and knowledge to care for them well. The service is run in the best interests of the people who live in the home. Information from the whole inspection process shows that the service is managed well and effectively. What has improved since the last inspection? The staff have implemented an ‘Individual Pathway’ to enable residents to identify and support staff to assist them achieve their ambitions during the year. The Registered Manager has ensured that all staff have updated their knowledge in regard to safeguarding and protecting the residents from possible abuse. The service’s provider has carried out a review of the management of the home to ensure that sufficient time is given for the administration and delivery of the service. What the care home could do better: There were a small number of good practice recommendations which were mainly about the administrative and record keeping practices that need to be put in place. Key inspection report CARE HOME ADULTS 18-65 60 Wood Lane Sonning Common Oxfordshire RG4 9SL Lead Inspector Ruth Lough Key Unannounced Inspection 13th August 2009 16:25 60 Wood Lane DS0000013219.V377212.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. 60 Wood Lane DS0000013219.V377212.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 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 60 Wood Lane Address Sonning Common Oxfordshire RG4 9SL 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) 01189 722080 jenny.pearce@new-support.org.uk www.new-support.org.uk Dimension (NSO) Ltd Mrs Jennifer Pearce Care Home 3 Category(ies) of Learning disability (0) registration, with number of places 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 3. Date of last inspection 19th August 2008 Brief Description of the Service: 60 Wood Lane is a three-bedroom house situated in a residential area of Sonning Common, close to shops and other amenities. It provides accommodation and care for up to three adults with a learning disability, either under or over 65 years of age. All those being supported are admitted on a permanent basis. The physical dependency of those being supported is increasing as they become older and consideration is being given as to how these needs can be met in the future. Social and Community Services purchase all the places in the home. The home is owned and managed by Dimensions (UK) Ltd. a charitable organisation that provides residential, supported living and outreach services for adults with a learning disability. The current charges are £654.00 per person per week. Extras include podiatry and hairdressing and those being supported buy their own toiletries, papers and magazines and pay transport costs out of their own weekly allowance. 60 Wood Lane DS0000013219.V377212.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. This was an unannounced key inspection process generated from the adequate findings identified at the last assessment of the quality of the service by the commission in August 2008. This inspection process included reviewing information provided by the service in the Annual Quality Assurance Assessment before a one-day visit to the home. An Annual Quality Assurance Assessment (AQAA) is a self assessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. The Annual Quality Assurance Assessment from this service was returned within the required timescales and had been completed satisfactorily. The registered manager was present when we visited the service on 13th August 2009, between 16:25 and 19:55 pm. During the day the records for care planning, recruitment, and administration of the service were assessed. Two of the people using the service were involved with the inspection process. We met with one member of staff and the area manager for the organisation who were present in the home. From this visit it was found that the requirements and recommendations that were made to improve the service during the last inspection process have been met. There were a few areas that will need to continue to improve and a small number of good practice recommendations were given at the time of the inspection and can be found in the body of this report. What the service does well: From information obtained through this inspection the people who use the service can be confident that they will obtain a good standard of care and support. They will also be provided with the opportunity to continue to with their daily lives as they wish. They can be certain that their concerns will be listened to and that they will be protected from possible abuse or harm by the systems in place. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 6 The service provides a homely comfortable environment that is able to accommodate their present needs and has the necessary equipment to do so. Staff are friendly welcoming and supportive and have be provided with the training and knowledge to care for them well. The service is run in the best interests of the people who live in the home. Information from the whole inspection process shows that the service is managed well and effectively. 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. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 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. There are the necessary procedures in place to ensure that individual’s needs are assessed prior to admission to the home. EVIDENCE: The service has not admitted any new residents to the home since the last inspection. The three current people who are receipt of support have been living together for around eleven years and are settled in their lives within the local community. The service has the necessary policies, procedures and processes to use should a vacancy in the home arise. These include obtaining information from health and social care professionals and providing any new prospective residents to opportunity to visit and stay before any decision is made to use the service. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 9 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, and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people in receipt of support can be confident that their individual plan will ensure that they will receive the care and assistance they need. EVIDENCE: The care records for two residents were reviewed to see what they have in place to instruct staff of how to provide the personal and social care support to individuals and how much of the decision making and participation the person concerned has in its development. Both records did show that the delivery of the information is focused on the key important aspects of their lives and is given in both a pictorial with brief written description for them to understand what is planned. Additional information is also supplied within risk assessments with the agreed interventions by staff. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 10 The records are spread over several folders, record books and an induction folder that is used for new or bank staff to the home. Therefore there are several sources for staff to follow how to provide the agreed care. The records reviewed clearly show the personal choices the person makes about their lives, their involvement in the care planning, and the review and development by the ‘key worker’ responsible for leading their support. For both individuals there were a number of risk assessments in place, those for general activities of daily living and for more specific events such as travelling in vehicles, work and going out in the community. They were advised to look at how they provide the information as to make them easier to access by staff to read. This was because the main person centred plan does not indicate that a specific risk assessment is in place and for some where there is a significant number, has the potential to be overlooked. The content these assessments were detailed and gave staff clear instruction of how to manage the risks appropriately. Where necessary staff have sought support from health professionals, such as those involved in the mental health treatment for individuals, as to develop them in accordance to their guidance. Staff note in good detail and are descriptive about the outcomes and the experiences of the person concerned in the individuals daily diary which is helpful to building a good picture of them. The only area that they need to improve is to put their full signature to any entry they record as to acknowledge their responsibility for completing it. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 11 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 and 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. The people who use the service are supported to continue with the lifestyle of their choice and have the opportunity to obtain new experiences. EVIDENCE: From discussion with staff and the two residents present during the inspection visit it was identified that each person has a documented ‘Individual Pathway’ which highlights the wishes and goals the person wants to achieve within the year. This information is held both in the persons care records and put up on display in the home for them to look at when they wish. The desired achievements are discussed in the reviews of care that are carried out and regularly with the person’s key worker. From looking at what is recorded each individual has both personal developments they wish to accomplish and those 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 12 that are based on activities and events that they enjoy. The residents we spoke to were enthusiastic about the proposed planned activities and from what we were informed and by looking at the photographs they had acquired, they have been able to achieve some of their ambitions already. One resident continues to work in the local community long after the government retirement date, and from what information was available he continues to enjoy it very much. He is supported well by staff to do so and the necessary monitoring is in place to see to ensure that it is appropriate and meets his needs. The other two residents are enabled to attend a day centre if they wish or remain at home with their own pastimes. Residents are given the opportunity to go on holiday and although not all have chosen to do so, those who have and have had a very enjoyable time and look forward to the next holiday. A programme of other day trips and events are provided in conjunction with individual’s wishes and joint events with the people who reside in the sister home, Wychwood Close. Each person has a weekly plan of activities that include household duties, individual time with a carer, and for their leisure interests. From speaking to staff and reading the entries individuals diaries it was evident that staff have a good understanding of the person’s choices of how they wish to conduct their usual daily lives. However, there are areas they could improve as to noting the usual pattern for daily routines such as rising from bed in the morning, evening and bedtime patterns which would be helpful to ensure continuity of care for individuals. Staff keep records of what each person’s likes, dislikes and dietary needs are in order to assist meeting personal choices for meals and requirements for health needs. Much of the information has been gained from seeking personal preferences from the individuals themselves and from the information they have obtained through the period of time caring for them. Each person has a planned menu for staff to follow, which is discussed with the individual and their key worker. During the inspection visit residents were seen to be asked again if they want what is planned for the evening meal and alternative are kept should it be required. Where concerns are raised about dietary intake staff record and monitor the person meals they have. From what could be seen, staff usually take the major responsibility for the preparation of meals although residents are encouraged to participate where they wish to and are able to do so. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 13 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 and 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 people who use the service are provided with the personal and healthcare support that they need and they are protected by the safe medication practices in the home. EVIDENCE: The records for personal and health care support were reviewed for one individual to see what interventions they have in place to meet their needs. Through discussion with staff and observation of this individual during the day it was apparent that their needs have gradually changed over the last few months giving rise to concerns by staff to their gradual deterioration of their physical and mental health. The health care records for this person were detailed and informative and supported that their general health needs were being met, such as dental, hearing and eyesight consultations and treatments. It was also apparent that early intervention by staff had ensured that specialist 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 14 medical assistance had been sought which has enabled them to start effectively planning of how to meet this person’s changing needs. This is with particular reference to the environment of the home, staff training and the relationships with the other people living in the home. The practices for medication administration in the home were reviewed to see if safe processes are in place. From information given by staff member on duty at the time of the inspection, none of the residents are able to manage their own medications. Staff take full responsibility for this and from information available training is given within the induction programme for new staff to enable them to carry out this role as soon as they are able. The records for medication that were viewed supported that staff are provided with good information about individuals needs and are recording appropriately in the MAR(Medication Administration Record) charts. Sample signatures of staff are taken to assist with monitoring and the movement of medications in and out of the home are recorded. Staff are given information about ‘over the counter’ or homely remedies that they can assist with should the need arise with the medication records. From what could be seen all medications are stored in an appropriate safe cabinet. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 15 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 and 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. The people who use the service can be confident that their concerns will be listened to and acted upon. They are also protected by the training and information given to staff in regard to safeguarding them from possible abuse or harm. EVIDENCE: Residents appeared to be confident in speaking to staff about any concerns or worries they may have. They are also provided with a pictorial complaints process which supports their rights to comment about the service or any concerns they may have. The home had a quality monitoring visit by the provider in March of this year where the assessor felt that improvements could be made in making the complaints information more accessible to residents. Information was given in this Annual Quality Assurance Assessment that this as been addressed. Residents have now been provided with a complaint’s booklet to use and staff had been provided with ‘Our Approach’ training which looks at within it, communication, interpreting and managing concerns should they arise. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 16 The Registered Manager provided information that there had been one formal complaint received since the last inspection process, details of which could be seen in the complaints record book. They were advised to look at how they record and monitor complaints and concerns made to the service as to maintain confidentiality and quality monitoring purposes. It could be seen in individual’s daily diaries that staff listen and act upon minor concerns expressed by the residents themselves. However, there is no central method of monitoring minor concerns or comments made which would be an effective way of looking at overall trends before they develop into a formal complaint. This observation was passed back to the manager. During the last inspection process some staff who spoke to the inspector did not express confidence about their knowledge for safeguarding adults from possible abuse or ‘whistle blowing.’ Since then the Registered Manager has ensured that a rolling programme of training has been carried out including some staff obtaining that on Deprivation of Liberty (DOLs) and the Mental Capacity Act 2005. One adult protection investigation had been instigated by the home through the local authority. From information provided the process was carried out appropriately and managed well. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 17 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 and 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 people who use the service are provided with a comfortable and homely environment that meets their current needs and ensures that they are part of the local community. EVIDENCE: The home is not purpose built but is a domestic dwelling a residential areas of Sonning Common. It is situated close by to the village shops and other facilities such as a health centre, post office, takeaways and public houses. There are also two local churches and a village hall where residents can enjoy being part of the local community should they wish. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 18 There are two main communal areas that residents can use, which is the lounge, leading into the dining room giving access to the kitchen at the rear and the staircase to the first floor. The home provides three bedrooms for residents on the first floor. The only bathroom is also on the first floor which used by both residents and staff. There is no specific area for staff to sleep or office area, the bed for sleep-in duty is placed in the dining room and some of the records for the home are stored in lockable filing cabinets in this room also. There has been no change in the overall facilities available to residents since the initial registration of the home before March 2002 and the size of bedrooms and communal amenities are not required to meet the current National Minimum Standards. The Registered Manager and the organisation have been aware that the premises may not be able to meet the needs of the current residents in the future and were able to demonstrate that they continue to seek assistance and advice of how provide for them in the future. However, recent changes in one individual’s health and well being may necessitate that they implement changes as soon as they are able. One change they have implemented to support this person is the provision of a bath aid to assist with their personal care, although all the residents now have to use this facility when they use the bath even though they may not require it. Generally the home provides a comfortable homely atmosphere that residents appear to enjoy. Each person has their own bedroom which they have been supported to choose and decide their own decoration, furnishings and fitments. It could be seen that they have personalised their rooms as they wished and have been supported as well as they are able, to take some responsibility to keep it clean and tidy. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 19 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 and 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 people who are in receipt of support are cared for by a consistent, trained team of staff that are able to meet their current needs. Staff are employed through a robust process that ensures that the vulnerable group of people living in the home are protected from inappropriate staff working with them. EVIDENCE: The staff team that supports the residents in both this home and the sister home, Wychwood, appear to be consistent and flexible to meet the needs of the people they support. Only one new member of staff has been recruited over the last six months and as yet, not completed their induction of probationary period of employment. The records for this one member of staff were reviewed to see if there is robust recruitment process that protects the vulnerable people living in the home. From what could be seen the necessary information had been obtained 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 20 for this new member of staff including Criminal Records Bureau and Protection of Vulnerable Adults list checks, before commencing work. From information given and that included in the service’s own quality monitoring review carried out by the provider in March 2009, the numbers, and level of skills and the pattern of shifts that staff are working in the home were assessed. The conclusion was from this assessment that the present needs of the people they are supporting were being met. However, the Registered Manager did confirm that this was always under review as to reflect the changing needs and activities of the residents. The home continue to have a small team of bank staff who know the residents well, should the need arise to replace or support the other staff employed. From observation of the member of staff working with the two residents in the home at the time of the inspection they appeared to have good communication between them. Both residents were comfortable and confident to express to the member of staff of what they wanted to do. The member of staff was also encouraging and supportive for the residents to be independent as much as they able to do so. The Registered Manager confirmed that seven of the nine permanent staff employed had attained an NVQ 2 and two were in the process of completing an NVQ 3. The training programme for the mandatory health and safety practices is ongoing, the training records that were reviewed also supported that all staff have had that for safeguarding adults, also. In addition there is training being provided to staff for the Deprivation of Liberty Safeguards (DOLS) and The Mental Capacity Act 2005. Further training is being sourced for dementia, nutrition and communication. All staff have been taken through ‘Our Approach’ which gives them key points of providing support and an understanding of the ethos of the organisation. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 21 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, and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is run effectively and safely and supports the people who live there. EVIDENCE: The service is led by an experienced manager who has been working in her current position for a number of years. In addition to being a registered nurse, she has an NVQ 4 in management. Since the last inspection process she has continued with her professional development with management training through the provider organisation. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 22 The manager continues to manage the two registered services and providing support to an individual living in the local community, under the organisations Supported Living Scheme. She is also included in the scheduling to provide personal care and support across the two homes. The quality assurance process carried out in March this year by the provider organisation also looked at the designated time given to the manager for the administration of the service and found that her management responsibilities are carried out satisfactorily and the home appears to be run well. The staff and the service have several methods of formally consulting with the residents about their opinion of what is provided. This includes the regular reviews of care with the individual, any health or social care professions who come in contact with the service and during the monthly visits to the home by the provider’s representative under Regulation 26. The information provided in the Annual Quality Assurance Assessment show that there are regular health and safety audits in place including reviews of general and individual risk assessments. A sample of some of the routine checks were reviewed This included the management of cleaning solutions that should be kept under Control of Substances Hazardous to Health Regulations (COSHH) 1988, hot water testing, and fridge and freezer temperatures. The records for these all supported that these are managed well and safely. 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Version 5.2 Page 24 60 Wood Lane DS0000013219.V377212.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. Refer to Standard Good Practice Recommendations 60 Wood Lane DS0000013219.V377212.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission South 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. 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