Care Home: 68 High Street

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What the care home does well Peoples’ care and support records were clear, comprehensive and personalised. People enjoyed living at the home, saying they ‘liked it’. There were a range of age appropriate activities for people living in the home and independence and decision-making was well managed. Staff were supported in their day to day work and there was a stable staff team that ensured consistency of care. The environment was comfortable and well maintained. A visiting professional felt the service had improved over the last twelve months and stated that they had ‘no concerns about the quality of the care’. 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 What has improved since the last inspection? A clear mechanism had been established for recording complaints and the action taken in response to them to ensure peoples’ concerns were addressed. All staff were booked to undertake safeguarding adults training to ensure the safety of all in the home. The staff rota was clear and established when the manager was available in the home. Medication administration practice had improved so that medication administration record charts were being properly maintained. Care plans, including risk assessments were being reviewed more regularly to ensure staff were acting on up to date information. Quality assurance processes had been improved by obtaining the views of relatives of people living in the home. What the care home could do better: There must be proper secure storage for controlled drugs that meets the recommended guidelines to ensure medicines are stored safely. The service should obtain a copy of the Royal Pharmaceutical Society Guidelines on handling medicines in social care and up to date medicines reference book. The service should obtain its own up to date copy of the Local Authority procedures on safeguarding adults. Recruitment records should always contain a fully completed employment history that accounts for any gaps in employment. There should be additional staff training courses on epilepsy and autism. There should be clear timescales laid down for the refurbishment of peoples’ bedrooms. The service should provide its information, including the complaints procedure, in an ‘easy to read’ version so that people in the home can understand it. The policy on dealing with peoples’ finances should be reviewed and amended to state that staff should not be involved in making wills and being beneficiaries.68 High StreetDS0000069782.V376709.R01.S.doc Version 5.2 Key inspection report CARE HOME ADULTS 18-65 68 High Street 68 High Street Loscoe Nr Heanor Derbyshire DE75 7LF Lead Inspector Janet Morrow Key Unannounced Inspection 22nd July 2009 12:00 68 High Street DS0000069782.V376709.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. 68 High Street DS0000069782.V376709.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 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 68 High Street Address 68 High Street Loscoe Nr Heanor Derbyshire DE75 7LF 01773 533075 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) M & A Dispensing Chemist Ltd Janet Wain Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning disability - Code LD The maximum number of service users who can be accommodated is 3 2. Date of last inspection 12th August 2008 Brief Description of the Service: 68 High Street, Loscoe, is a small care home registered for up to 3 people with a learning disability. The Home is a terraced house, situated in a residential area, on a main road. Each service user has their own single bedroom. The Home has not been adapted for people with physical difficulties and it has steep stairs leading to the bedrooms and bathroom. The Home has a small staff team operating on a rota basis, providing one member of staff on duty at all times when service users are at the Home. The current service user group all have a moderate to mild learning disability so that the Homes service are geared up to high levels of independent activity. There is parking space for one car. Verbal information supplied in July 2009 stated that the weekly fees were £380.45. Copies of inspection reports can be provided by the manager of the home and are available on the Care Quality Commission’s website at www.cqc.org.uk 68 High Street DS0000069782.V376709.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 inspection visit took place over one day for a total of 3.25 hours and concentrated on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection in August 2008. The manager and two members of staff were spoken with and three people currently accommodated in the home were also spoken with. One visiting professional was spoken with by telephone following the inspection visit. Case tracking methodology was used; this means that the records of one person were examined in detail and feedback sought from relevant people to assess what impact the service had on the person’s health and well-being. Four surveys were returned to the Care Quality Commission shortly after the inspection visit; two from people living at the home and two from staff. Care records, a sample of policies and procedures and staff information were examined. A tour of the building took place. Written information in the form of an annual quality assurance assessment was provided by the service prior to the inspection visit and this informed the inspection process. What the service does well: Peoples’ care and support records were clear, comprehensive and personalised. People enjoyed living at the home, saying they ‘liked it’. There were a range of age appropriate activities for people living in the home and independence and decision-making was well managed. Staff were supported in their day to day work and there was a stable staff team that ensured consistency of care. The environment was comfortable and well maintained. A visiting professional felt the service had improved over the last twelve months and stated that they had ‘no concerns about the quality of the care’. 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There must be proper secure storage for controlled drugs that meets the recommended guidelines to ensure medicines are stored safely. The service should obtain a copy of the Royal Pharmaceutical Society Guidelines on handling medicines in social care and up to date medicines reference book. The service should obtain its own up to date copy of the Local Authority procedures on safeguarding adults. Recruitment records should always contain a fully completed employment history that accounts for any gaps in employment. There should be additional staff training courses on epilepsy and autism. There should be clear timescales laid down for the refurbishment of peoples’ bedrooms. The service should provide its information, including the complaints procedure, in an ‘easy to read’ version so that people in the home can understand it. The policy on dealing with peoples’ finances should be reviewed and amended to state that staff should not be involved in making wills and being beneficiaries. 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 7 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. 68 High Street DS0000069782.V376709.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 68 High Street DS0000069782.V376709.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): 2 and 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 was sufficient pre-admission information available to establish that the home was able to meet peoples’ needs. EVIDENCE: All the people living at the home had been admitted through the Local Authority care management system and assessment information was available from that process. The written information supplied by the service stated that ‘a full assessment is given prior to admittance to the home to ensure that needs can be met’. One person’s care and support file was examined. This showed that there was information available from the assessment and care management system and the service had also completed its own documentation. An individual care and support plan was in place based on an initial assessment of the person’s needs. 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 10 Both surveys received from people living in the home responded that they received enough information about the service before deciding to move in. 68 High Street DS0000069782.V376709.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 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. Clear care planning and the promotion of independence ensured that people could make individual choices and manage any risks safely. EVIDENCE: The written information supplied by the service stated that it promoted ‘independence and risk taking, service users encouraged to make individual choices’. One person’s care and support file was examined and showed that a care and support plan was in place that demonstrated how individual needs would be met. These were detailed and informed staff how to manage any difficult 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 12 behaviours as well as how to assist and encourage with daily activities, such as personal care. There were risk assessments in place for key areas of support such as managing dietary needs, independent travel and challenging behaviour and these contained details on how to manage any risks safely. They were last reviewed in June 2009. Staff spoken with were able to demonstrate that people were able to take risks within a risk management framework. Discussion with staff showed how some people made decisions and choices and had relatively high degrees of independence in certain situations, including the use of public transport and in personal finance. Discussion with people living in the home showed that they were able to make decisions and choices about their daily routines and spent their free time in activities of their own choosing. One person explained that they had been to meetings and the theatre and another discussed their job. All were able to choose and make drinks and snacks for themselves independently. Both surveys from people living in the home responded that they ‘sometimes’ made decisions about what to do each day but said it depended on ‘other service users’. The manager stated that no one currently had an advocate but she was aware of who to contact if necessary and had information on the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards. 68 High Street DS0000069782.V376709.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 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 service provided activities and opportunities that were age-appropriate and valued by people and promoted their independence. EVIDENCE: The written information provided by the service stated that it promoted ‘service users independence and leisure around service users preferred choices including food preferences to maintain a healthy lifestyle’ and ‘support is given to service users who attend day centres and college’. People living at the home were able to say how much they liked the activities they were involved in; this included a variety of hobbies such as dancing, computer games, music and sport. They went out most days to a local day 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 14 centre, visiting family and one person had a part time job at a local golf club. A holiday abroad was planned and all were looking forward to going. The range of options available showed that effort was made to structure activities around individual likes and dislikes and in areas that had the capacity for personal development. Both surveys received from people living in the home responded that they could do what they wanted each day. One person’s care and support records were examined and these showed the range of activities on offer, which were confirmed in conversation. Visiting hours were open and families were able to visit when they wished. Food stocks in the kitchen were at a good level. There was evidence of peoples’ individual tastes being catered for – with food bought by themselves placed on labelled shelves in the kitchen wall cupboards. All people spoken with were positive about the food they ate. The written information supplied by the service stated that ‘encouragement given to service users to participate in the preparation and cooking of meals’. This was confirmed by staff spoken with, who stated that everyone joined in cooking the main meal according to their abilities. During the inspection visit, two people were observed to make themselves a drink and one person made themselves a snack. 68 High Street DS0000069782.V376709.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 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. Peoples’ health and personal care needs were well managed, which ensured that good health was maintained. EVIDENCE: The written information supplied by the service stated that ‘all service users access local health professionals. All outcomes are recorded in personal files and Health Files’. One person’s health file was then examined and showed that all essential health information including weight monitoring and visits to General Practitioner (GP), optician etc were recorded. Medical appointments and outcomes were well recorded. During the inspection visit, it was observed that privacy and dignity was observed; each person had their own key to their bedroom door and staff were 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 16 observed to knock before entering. Staff interactions were polite and courteous. A visiting professional spoken with said that staff at the service managed peoples’ needs well and that there had been improvements over the last year. They described one of the people they were involved with as ‘content’. One person’s medication administration record (MAR) chart was examined and showed that this was being completed accurately with amounts of medicine received recorded and codes being used properly, where applicable. It was accurate and corresponded with the medicine administered. There were specimen staff signatures available and a photograph to aid identification of each person. Medicines were stored securely but the service did not have storage for controlled drugs that met recommended standards. This was raised as an issue at the previous inspection visit in August 2008. However, the home’s policy state that controlled drugs were ‘to be kept in a locked cabinet with the specifications laid down in the Regulations’. The service was therefore not following its own policy. Failure to implement proper storage for controlled drugs may lead to action being taken by the Care Quality Commission to ensure compliance with this requirement. A copy of the Royal Pharmaceutical Society guidelines on handling medicines in social care and an up to date medicines reference book could not be located during the inspection visit. Staff spoken with confirmed that they had completed medication training in the past and that they were booked on to a refresher course in September 2009. 68 High Street DS0000069782.V376709.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 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. Clear procedures ensured that peoples’ concerns were addressed objectively and that they were safeguarded. EVIDENCE: The content of the home’s complaints procedure was satisfactory and stated that complaints would be responded to within fourteen days. The written information supplied by the service stated that it encouraged ‘discussion at service user meetings or informally within the home’ to try and resolve any issues. It also stated that no complaints had been received since the previous inspection visit in August 2008. There was a format for recording complaints but this had not been utilised as no complaints had been received. There had also been no complaints received at the office of the Care Quality Commission in the last twelve months. Both surveys from people living in the home responded that they knew how to make a complaint and who to speak to if they were unhappy. One of the two staff surveys received commented that if there were any problems, people ‘seem to voice their thoughts with no worries’. 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 18 The service’s financial policy was examined and gave instructions on how peoples’ financial affairs should be dealt with. However, there was no information in the policy on dealing with peoples’ wills and being a beneficiary. The financial records of personal allowances for two people living in the home were examined. These showed that the persons concerned were signing the record with the staff member. The cash held corresponded correctly with the written records and was stored securely. The service had a policy on safeguarding adults and also had information from the Local Authority on reporting procedures available at its other home in the area, although this was not the most up to date version. Both members of staff spoken with were aware of their responsibility to report any suspicions of abuse and confirmed that safeguarding training was undertaken. Diary entries showed that this training was booked for August 2009. 68 High Street DS0000069782.V376709.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, 26 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 premises were well maintained, providing homely, safe and comfortable accommodation for people living there. EVIDENCE: The premises provided people living there with a homely and domestic environment. It was clean and well maintained and there were no odours. Both surveys received from people living in the home responded that the premises were ‘always’ fresh and clean. 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 20 To the rear there was a conservatory, patio and small garden. Each person had their own bedroom, with a door that locked if they wished. Two bedrooms were seen on this inspection visit and were well personalised, although small in size. One person showed pride in their personal possessions and said they ‘liked’ their room. The written information supplied by the service stated that ‘Carpets curtains and some furniture has been replaced, all rooms decorated, washing machine tumble dryer iron have been replaced when the items have broken’ and also further decoration and refurbishment were planned over the next year. However, both staff surveys received commented that more should be done regarding ‘decorating their bedrooms’ and a visiting professional commented on the length of time taken for the refurbishment of peoples’ bedrooms. The laundry facilities were domestic in nature and satisfactory. There was secure storage for cleaning materials. Staff spoken with knew how to control the spread of infection and confirmed that there were plenty of gloves and aprons available for use. 68 High Street DS0000069782.V376709.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 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. Training and recruitment practices were thorough, which ensured that staff had the skills to care for people. EVIDENCE: The staff rota for the week beginning 20th July 2009 was examined. This showed that there was one staff member on duty on each shift. There was one sleep in staff at night. Both the manager and staff members spoken with felt there were enough staff available to provide the care required. One staff survey responded that there were ‘always’ enough staff to meet individual needs and one responded that there ‘usually’ were. The written information supplied by the service stated that two of the three staff members at the home had achieved a National Vocational Qualification at 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 22 level 2 or above. One person had achieved a level 3 qualification. This meant that the home was meeting the target of having 50 of staff qualified to NVQ level 2 or above. One staff file was examined for recruitment records. This showed that a thorough recruitment process was operated and that most of the information required by Schedule 2 of the Care Homes Regulations 2001 was in place, including evidence of Criminal Record Bureau (CRB) checks, qualifications and two written references. However, the employment history was not fully completed. Both staff surveys received confirmed that recruitment checks took place before employment began. Staff training information examined showed that mandatory health and safety training was undertaken as well as other training in relation to the needs of the people living at the home. Training certificates showed that courses undertaken since the last inspection in August 2008 included epilepsy and one staff member spoken with confirmed that they were due to undertake training on the Mental Capacity Act. Staff spoken with confirmed that access to training was good. One member of staff stated that additional training on epilepsy and autism would be beneficial. One staff survey received responded that relevant training was given, the other did not provide a response. 68 High Street DS0000069782.V376709.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, 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 home was well run in the best interests of people living there. EVIDENCE: The manager was registered with the Care Quality Commission. The written information supplied by the service stated that ‘the manager spends more time within the home now doing a support shift once a week. Support given to staff on a regular basis.’ This was confirmed by those staff spoken with. One also stated that ‘everything runs smoothly’. One staff survey responded that they 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 24 met ‘regularly’ with the manager to discuss work and the other responded that they ‘often’ did. Quality assurance processes had been developed further and recent surveys to gain the views of relatives had been undertaken in July 2009. Most areas surveyed received responses of ‘very good’. Other comments received were ‘seems to be very happy with life’ and ‘calls it home’. One issue raised had been satisfactorily addressed. The owners were undertaking monthly audits, as required by Regulation 26 of the Care Homes Regulations 2001, and records of these visits showed how they intended to improve. Meetings with people living in the home were also held and notes from these were seen from January 2009 and April 2009. Staff spoken confirmed that health and safety training was undertaken in food hygiene, first aid, moving and handling and fire safety and this was confirmed on training records seen, which stated that this training had occurred between November 2008 and February 2009. The written information supplied by the service stated that maintenance checks were undertaken regularly; records seen in the service confirmed that portable electrical appliances had been tested in March 2009, electrical wiring had been checked in 2008 and gas safety in August 2008. 68 High Street DS0000069782.V376709.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 X 2 3 3 3 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 3 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 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Version 5.2 Page 26 68 High Street DS0000069782.V376709.R01.S.doc YES 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 A secure facility must be provided to recommended specifications to ensure the safe storage of controlled drugs. Previous timescale of 30/11/08 not met; timescale extended until 30/09/2009. Timescale for action 30/09/09 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. Refer to Standard YA20 Good Practice Recommendations The service should obtain a copy of the Royal Pharmaceutical Society Guidelines on handling medicines in social care and up to date medicines reference book. The service should provide its information, including the complaints procedure, in an ‘easy to read’ version so that people in the home can understand it. The service should contain its own up to date copy of the DS0000069782.V376709.R01.S.doc Version 5.2 Page 27 2. YA22 3. YA23 68 High Street Local Authority procedures on safeguarding adults. 4. YA23 The policy on dealing with peoples’ finances should be reviewed and amended to state that staff should not be involved in making wills and being beneficiaries. There should be clear timescales laid down for the refurbishment of peoples’ bedrooms. Recruitment records should always contain a fully completed employment history that accounts for any gaps in employment. There should be additional staff training courses on epilepsy and autism. 5. 6. YA26 YA34 7. YA35 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 68 High Street DS0000069782.V376709.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!