Care Home: 8 Graeme Close

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What the care home does well Staff and residents spoken with and comments from surveys indicate that morale in the home was good. Staff were cheerful and interacting with residents in a positive and caring manner and people are treated with respect and dignity The home was found to be clean, warm and in good order. Residents were calm relaxed and state they are well cared for. We spoke to three residents during the visit. Residents surveyed said “Staff always treat me well” comments included, “the home radiates warmth”, and “nice and clean, good staff and cooking” What has improved since the last inspection? The care plans are accurate and reflect any updated reviews and staff regularly monitor the care plans. The staff team have developed an approach to supporting residents meet their needs identified in their care plans and encourage residents to sign their plans. Staff personnel files contain the specified documentation. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 At all times there are suitably qualified, competent and experienced persons are working at the home in such numbers as appropriate for the health and welfare of service users. Carpet areas, which have cigarette burns in general have been replaced or repaired. What the care home could do better: Create chronological Registered nurse training records related to clinical and mental health learning and up dating, detailing the date facilitator and duration of the learning. Keep all documentation relating to complaints together and separate out issues raised by residents complaining about other residents. Appropriate measures must be taken to ensure the staff and residents are protected from outbreak of fire due to smoking. Key inspection report CARE HOME ADULTS 18-65 8 Graeme Close Fishponds Bristol BS16 3SF Lead Inspector Andrew Pollard Key Unannounced Inspection 4th November 2009 09:00 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service 8 Graeme Close Address Fishponds Bristol BS16 3SF 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) 0117 9652696 0117 9652696 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Elva Verretta Bennett Care Home 16 Category(ies) of Dementia (16), Mental disorder, excluding registration, with number learning disability or dementia (16) of places 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 16 Adults with Mental Disorder excluding those detained under the Mental Health Act 1983 Staffing Notice dated 02/07/1999 applies Manager must be a RN on parts 3 or 13 of the NMC register Date of last inspection 30th July 2007 Brief Description of the Service: Graeme Close is a registered care home providing 16 nursing care places for people between 18 and 65 years of age who have mental health difficulties. The home cannot accept people detained under the Mental Health Act. The building was purpose built in the late 1990’s and offers care over two floors, there is a lift, which gives wheelchair access to the upper floor. Accommodation is offered in single rooms and there is a variety of communal space and quiet rooms. The house is very near to the Fishponds shops, local social venues and is situated on a main bus route. The home encourages residents to be as independent as possible with support and empowerment from full time care staff lead by a team of Registered Nurses. The home is operated as part of the Aspects and Milestones charitable trust. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that the people who use the service experience good quality outcomes. The following methods of evidence gathering has been used In the production of this report; observation, AQAA questionnaire, discussion with residents and staff, residents surveys, tour of the home and sampling policies, records, care plans. The emphasis of the service is predominantly long term care and rehabilitation where appropriate. The aim is to enable people to maintain good mental health and a more independent lifestyle. In addition staff strive to enhance the quality of life for the residents. The staff team are experienced with the needs of the resident group. The skill mix and level of Registered Nurse input is appropriate for the resident group. What the service does well: What has improved since the last inspection? The care plans are accurate and reflect any updated reviews and staff regularly monitor the care plans. The staff team have developed an approach to supporting residents meet their needs identified in their care plans and encourage residents to sign their plans. Staff personnel files contain the specified documentation. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 6 At all times there are suitably qualified, competent and experienced persons are working at the home in such numbers as appropriate for the health and welfare of service users. Carpet areas, which have cigarette burns in general have been replaced or repaired. 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. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 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. Prospective clients and their families are given relevant information and terms and conditions in written or verbal form about the home to assist them in deciding if the home is suitable for their purpose. As a result of effective assessment of needs prospective residents can be confident that these will be met in a manner that suits the individual. EVIDENCE: 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 9 The home has an equalities and diversity policy and is open to admissions from people of all backgrounds and cultures. Graeme Close is a person centred home is relaxed and homely and seeks to maintain residents life skills providing therapeutic support where needed. The statement of purpose and service user guide has been written in accord with the regulations and schedules and provides clear information for residents. The contact details for the commission have been updated with the new address. Recently residents designed a butterfly logo for the homes documentation. All admissions are managed through the community mental health team and social services that carry out full assessments of peoples needs. The prospective residents, professionals and relatives are consulted where appropriate. The manager or other Registered Mental Nurse meet and assesses people prior to admission in the majority of cases. Prospective residents are offered half-day visits and meals as a method of determining if the home suits them. Admissions can be arranged at short notice if sufficient information is available. The views of the existing residents are taken in to account regarding any admission. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9, 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. There was evidence of needs and risk assessments reviews being carried out and clearly written care plans. Residents are involved with decision-making and consulted about the running of the home within the limits of their willingness or ability to take part. EVIDENCE: All residents have a person centred care plan, which they were encouraged to take an active part in developing. Some residents require staff support in this process and some play a very limited part. All of the residents who responded in the survey said, “Staff listen and act on what they say”. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 11 A named lead nurse is responsible for the care planning process with residents and key workers. For other residents a care plan is developed from observed behaviours. Residents are asked to sign the document as an indication of their agreement with the plan of action. Key workers monitor care plans on a three monthly basis, and compile a brief summary on the progress made during the month. Resident’s files had been organised in a systematic manner so care plans and risk assessments were linked together. Each element of the care plan is written up separately and signed by the resident. Evaluations and daily records are written in the case file. Enhanced level care plans and medical information are also part of the case file. There are regular multidisciplinary reviews to which residents and or their representative are invited. Risk assessments are in place for activities that may involve an element of risk such as smoking, road safety, self-care, hygiene and checking at night. It is evident that a number of residents smoke outside the designated areas. While it is acknowledged that precautions are taken to prevent a fire at the home, decisions must be made about smoking in bedrooms. It is clear that residents are informed about the smoking policy and continue to disregard the rules on smoking. Appropriate measures must be taken to ensure the staff and residents are protected from outbreak of fire. Any staff control over an individuals smoking kit must evidence the person was involved in the process and the agreements put in place. One person has restrictions imposed on freedom and choice for a separate matter and a full Deprivation of Liberty assessment has been carried out. Residents meetings are both formal and informal and the staff are empowering toward the residents and encourage their involvement in decision-making. Regular residents meetings are held chaired by the activity organiser. People indicated in the survey that they could do what they want during the day and at weekends. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,14,16,17 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. Care plans detail residents care needs they are clearly written and give directions to staff. A person-centeredness approach enhances the quality of care for residents. Staff strive to enhance the quality of life for the residents. EVIDENCE: The emphasis of the service remains continuing care and some rehabilitation, also to maintain the existing life skills that people have. Where appropriate the long-term aim is to lead people toward a more independent lifestyle in the community. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 13 The long-standing mental health needs of the residents often militate against the likelihood of future employment or further education. One person spoken to is on placement and is doing an NVQ in horticulture Residents regularly make use of community facilities and services. There is a wide range of activities available for the residents. There is a full time activity co coordinator and a part time co-ordinator who maintains a folder that lists what the residents do during the day. Each resident has an activities profile and detailed records of their engagement are kept. These activities include a weekly art group, music and movement and a chat group so the residents can keep up to date with events in the outside world and give their views. A training kitchen is available for residents to cook with supervision. A ten-year party for the home was held recently and food and entertainment from other cultures was provided. The activity coordinator and part time coordinator plan the menu weekly with the residents and their choices were listed. From speaking to residents and reviewing records it was evident that the food provided is to peoples liking and offers a generally balanced diet. There is one person with special cultural needs who has a Halal diet. There is one person who is a diet controlled diabetic. All bar one resident surveyed were happy with the meals. One person is a Bengali speaker who has limited English and in her DOL’s plan it was recommended that an advocate or other Bengali speaker be brought to the home weekly to help reduce her social isolation. To date this has not happened but the manager is making enquiries to find a suitable person. I later have been informed that this facility is being re-instated on a weekly basis. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 medication policy of the home is being complied with. There are effective arrangements in place to meet residents mental and physical healthcare needs. The home has all the specialist equipment required to meet the resident’s needs. EVIDENCE: 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 15 Registered nurses administer all other medication including depot injections. All Nurses are Registered Mental health or Learning Disability Nurses. All residents have a medication profile. Only two residents are assessed as safe to part self medicate and have custody of their drugs, which is closely monitored. Competence assessments and a supporting policy for self-medication are in place. There is a local medication policy as an adjunct to the Trust document including homely remedies. The home has a file containing drug alerts. The receipt and administration and disposal records were in order. Regular stock checking takes place. No Controlled Drugs are in use at present. All residents remain under the care of a consultant Psychiatrist. All residents are registered with a local GP practice that makes referrals for any paramedical services required. Dental checks and eye tests are arranged for those who wish for such. Some people are able to be independent in accessing medical services the others require general support. All residents need some degree of prompting or support in managing their personal hygiene. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. The staff are aware of the Trusts complaints and Safeguarding policies and are trained in putting them into practice to protect residents from abuse. The residents are aware of the complaints procedure and attend meetings to give their views on the running of the home. EVIDENCE: 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 17 The complaint procedure meets CQC requirements and is available to residents and families where appropriate. All residents who responded to the survey indicated, “They were aware of whom to complain to if they were unhappy with their care”. Each resident has been given a copy of the service user guide containing the procedure and a copy is pinned to the notice board to raise people’s awareness of the process There is a complaint log in place. The documentation relating to complaints, investigations and outcomes are not all kept together and it may be helpful to do this. All complaints have been resolved. There are complaints from residents about other residents, which may be better held in case files, as they are not directly complaints about the service. One resident spoken with had a complaint about a fellow resident; the manager reassured them that it was being dealt with. The Bristol “No Secrets” guidance is available and a whistle blowing and safeguarding policy are in place. All of the staff have attended alerter level safeguarding training and further updates are planned Each resident has a specific recording sheet relating to his or her finances. All residents have a balance sheet for any monies held for safekeeping and receipts supporting expenditure. All money is checked thrice daily and double signed. All residents have a bank account, some of who require varying levels of staff support with managing their finances, a number handle their own personal allowance. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,30 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 house is a clean, comfortable and safe environment for the current residents. The bedrooms and communal rooms and facilities are suitable for their purpose and meet the resident’s needs. EVIDENCE: 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 19 The home is suitable to meet the current needs of the residents who are all ambulant. The home was clean and in good general order. The resident’s survey said “The home was always clean and fresh” and one person said “Usually”. Residents take some responsibility for maintaining their own rooms. The fittings and furnishings are of a domestic nature and are in generally good order. The standard of décor is satisfactory. The heating, lighting and ventilation are in order. Appropriate arrangements are in place for maintenance and servicing of plant and equipment, for which records are kept. Bedrooms are decorated and furnished in accord with resident’s wishes. Some bedrooms are personalised and others very plain, but this may reflect to some extent certain residents lack of motivation and the fact that people do not generally spend much times in their rooms. Rooms are lockable and residents have access to keys if they wish. There are bathrooms and showers that are suitable for the residents needs. Communal areas include a dining room, lounge, conservatory and quiet room. A training kitchen is used by one resident who in part self caters and for other residents with supervision. All people make their own beverages. The main kitchen has been inspected by the Environmental Health Officer and awarded 4 stars. The sluice and laundry are adequately equipped. Department of Health guidelines on infection control are available. Proper arrangements are in place to dispose of clinical waste. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,36 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. An appropriate and robust recruitment procedure is in place. The staff are experienced and trained to meet the individual and joint needs of the residents. The staff skill mix and staffing levels are conducive to maintaining and enhancing the resident’s quality of life. An increased focus on Registered Nurse training is needed. EVIDENCE: 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 21 Staffing levels are in adequate in the manager’s opinion. The manager works supernumerary five days per week. If resident’s needs or dependency changes the manager has the authority to bring in additional staff. At present one resident is in receipt of one to one support. There is low usage of bank and agency nursing staff and somewhat more for support staff. All bank staff complete an induction on their first shift. The skill mix and level of Registered Nurse input are appropriate for the resident group. The staff team are experienced with the needs of the resident group and are client centred. All bar one of the residents who responded to the survey said, “That the staff treat them well”. Five people said that “Staff listen to them and act on what they say”, two people said sometimes. A member of staff said,” this is a very unified place to work. We have the needs of the residents at heart and also their safety and well being”. The trust has a robust and comprehensive recruitment and employment policy. The staff files reviewed were up to date and in good order. Housekeepers and catering staff work five days per week. A full time activity organiser works over five days per week and a part time person over three days per week. A rolling programme of updates in Health & Safety (H&S), 1st aid, food hygine and load handling takes place. There is evidence from records and staff comments about mandatory learning and updating for all staff. One person has National Vocational Qualification (NVQ) level 2. Five staff are on NVQ level 2 programmes. We discussed an increased focus on Nurse training to update their nursing skills and ensure they are carrying our research-based practice. All staff receive six to eight weekly supervision by a cascade system of which written notes are made.The manager conducts an annual appraisal process using documentation supplied by the Trust. It is suggested that this process be used to review RN learning relevent to PREP and to to create learning development plans. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. The staff are motivated to bring about improvements in residents quality of life. The staff seek to empower the residents and safeguard them from abuse. The home is a safe and well-maintained home. EVIDENCE: 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 23 The manager and nursing staff are experienced in the care for people with mental health needs. The manager has compleated the registered managers award. There is low staff turnover in the home and the consistency of staff presence is important to the wellbeing of the residents and maintaining the strategies of care that prevent incidents and tensions arising in the home. Whole team meetings are held regularly to review practice and standards of care. Regular house meetings are held to access the views of the residents on the quality of life and services in the home. All the residents stated that, “The staff treat them well” one person saying, “ They look after me” and another saying, “It’s a nice place”. one member of staff commented that the home was “person centred,had supportive management and proactive and productive team work”. the are monthly all staff meetings and records are kept. Home managers within the Trust meet together each month chaired by Mr Altoff the community manager who also visits the home at least monthly and writes the Regulation 26 report. The Trust has a comrehensive range of policies and procedures and arrangements to review them. There are a range of local policies in place. There is a comprehensive Health and Safety policy and there is a Trust manager who has delegated responsibility for such matters. Safety audits take place regularly. All residents have individual risk assessments which were seen to have been regulary reviewed. Each person also has a written competence statement for individual life skills as appropriate. The fire log book, records and alarm/detector maintenance arrangements were up to date and in order. The gas safety, lift and electrical safety inspections have taken place according to the managager but the certificates were not available and continuing service contracts remain in place. 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000020242.V378044.R03.S.doc 3 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 8 Graeme Close Score 3 3 3 x 3 X 3 X X 3 x Version 5.3 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA42 YA22 Good Practice Recommendations Appropriate measures must be taken to ensure the staff and residents are protected from outbreak of fire due to smoking. Keep all documentation relating to complaints together and separate out issues raised by residents complaining about other residents. Create chronological Registered nurse training records related to clinical and mental health learning and up dating, detailing the date facilitator and duration of the learning. 3. YA35 8 Graeme Close DS0000020242.V378044.R03.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission South West 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. 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