Care Home: A M Care Home Ltd

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What the care home does well People wanting to move in get good information about the home and it is written in pictures as well as words.A M Care Home LtdDS0000071579.V377131.R01.S.docVersion 5.2People are helped to choose what they want to do and when they want to go to bed and when they want to get up. People are supported to do lots of different activities both in and out of the home. The home is clean and tidy. Staff are experienced and well trained. What has improved since the last inspection? This is the home’s first key inspection. What the care home could do better: The manager should make sure that his information paperwork is looked at regularly and kept up to date. Key inspection report CARE HOME ADULTS 18-65 A M Care Home Ltd 56-58 Lodge Lane Grays Essex RM16 2YH Lead Inspector Pauline Marshall Key Unannounced Inspection 1st September 2009 09:25 A M Care Home Ltd DS0000071579.V377131.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. A M Care Home Ltd DS0000071579.V377131.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 A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service A M Care Home Ltd Address 56-58 Lodge Lane Grays Essex RM16 2YH 01375 379134 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) vrlogan@hotmail.com AM Care Home Limited Vyramuthu Rattinam Loganathan Care Home 8 Category(ies) of Learning disability (8), Mental disorder, registration, with number excluding learning disability or dementia (8) of places A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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 categories: Learning Disability - Code LD Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is 8 2. Date of last inspection 9th September 2008 Brief Description of the Service: AM Care Home provides twenty-four hour care for up to eight people with learning disabilities who may also have mild to moderate mental health needs. There are eight single bedrooms, six with en-suite facilities, a lounge, a dining room, a kitchen, a communal bathroom and a large garden. There is parking to the front of the building and on street parking in the road outside the home. The home is situated in Grays and it has easy access to the local shops and Lakeside shopping centre. There are buses and trains nearby and the home has its own people carrier. A copy of the homes Statement of Purpose and Service User Guide is available from the home by request. Fees are £1200 per week; there are additional charges for toiletries, clothing, outings, holidays and personal items. Included in the fees is an allowance of £20 per week per person towards the cost of an annual holiday. A M Care Home Ltd DS0000071579.V377131.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 stars. This means that people who use the service experience good quality outcomes. AM Care Home Limited was registered on 4th April 2008 and a key inspection was planned for the 9th September 2008. On the day of our visit there were no people living in the home but one person had stayed there on a trial visit and the manager had carried out two preadmission assessments for people that wanted to move in. There were records for four staff that had been recruited and had worked at the time of the trial visit. Due to there being no people living in the home we replaced the key inspection with a random inspection as laid down in our methodology and any comments from this have been included in this report. We visited the home on 1st September 2009 and looked at some of the resident and staff files. We also looked at the policies that explain how the home does things. We looked around the home and spoke to the staff and the manager. We read the information in the managers’ annual quality assurance assessment (AQAA). This is a document that the manager has to complete by law; we have used the information provided in the AQAA in this report. We talked to people living in the home and watched what was happening. We sent surveys to people living at A M Care Home and to some of the staff to see what they think about the home. What the service does well: People wanting to move in get good information about the home and it is written in pictures as well as words. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 6 People are helped to choose what they want to do and when they want to go to bed and when they want to get up. People are supported to do lots of different activities both in and out of the home. The home is clean and tidy. Staff are experienced and well trained. 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. A M Care Home Ltd DS0000071579.V377131.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 A M Care Home Ltd DS0000071579.V377131.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): 1, 2, 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. People know that their needs can be met within the home. EVIDENCE: A copy of the Statement of Purpose and Service User Guide are displayed in the hallway next to the home’s visitor’s book. Both documents have pictures in addition to the written word and have been recently reviewed and amended to include up to date information. People spoken with confirmed that the documents provided them with sufficient information about the home. We looked at four care files and each of them included a thorough pre admission assessment that had been carried out by the manager before the individual moved into the home. Each of the assessments that we looked at covered all areas of need such as personal care, physical well-being, diet and allergies, dietary preferences, sight, hearing, communication, oral health, foot care, mobility and dexterity. The assessments looked at any mental health issues and clearly identified the level of domestic skills people had. The A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 9 random inspection showed that thorough pre-admission assessments had been carried out for two people that were interested in living in the home. The manager said in his AQAA “I conduct an assessment of needs prior to the service users admission to the care home and during this assessment of needs it is assessed whether we can provide appropriate care that will meet service users needs and then the service users are offered to visit the care home”. People spoken with confirmed that they had a full assessment before moving into the home and that the assessment covered all areas of need including their social, emotional and healthcare needs. One person spoken with said they had visited the home before making the decision to move in. Each of the care files that we looked at contained copies of the individuals’ contract with the home in addition to their local authority placement agreement and people spoken with confirmed that they had been provided with a contract that the manager had explained to them. Each of the contracts was signed by both the individual and the manager. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 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. People receive appropriate individualised care based on their identified needs. EVIDENCE: We looked at four care files and the support plans were detailed and informative, they looked at all areas of need such as physical, health care, social and emotional and they identified the level of support that each individual required. People living in the home confirmed that the staff supports them as described in their support plan and one person said “I worked with the staff to write my plan and it is now being improved upon with my help”. The deputy manager said that key workers are in the process of developing person centred plans for each of the people living in the home and there were two completed files to support this. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 11 People spoken with said that they were fully involved in all areas of their care and that regular meetings were held; there were written notes to confirm this. Staff was observed interacting with people living in the home and it was clear from their conversations that people were able to make their own decisions such as where they wanted to go and what they wanted to do. People spoken with said “we decide where we go and staff respect that, we are very happy here”. One person living in the home said in their survey “I like everything here and I don’t want to move”. An assessment of domestic skills is carried out prior to people moving in and people are given ample opportunity to participate in the day to day running of the home. People spoken with said that they found the use of pictures in the documentation helpful in understanding the meaning of the words. The random inspection report showed that there were some shortfalls in the home’s risk assessment; it did not fully describe the risk and how staff was to manage it. We looked at all of the risk assessments on four of the care files, these included risk assessments for swimming and accessing the community as well as for personal care risks; each of them clearly identified the risks and how staff was to manage them. Each of the support plans and risk assessments had been reviewed on a regular basis. One of the people spoken with said that the staff always consulted them on any changes that had to be made to either their support plans or their risk management plans. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 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, 15, 16, 17 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are well supported to live a lifestyle that meets their identified needs and preferences. EVIDENCE: People spoken with said that they lived a full and active life at A M Care Home and that the staff supported them to go swimming, shopping, to clubs and on annual holidays. The support plans showed that people regularly visit local amenities such as the local pub, bingo hall and swimming pool at the local leisure centre. The records showed that one person goes swimming three times each week and that all of the people living in the home have attended local clubs on a regular basis. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 13 Activities are planned by each individual together with their key worker and the weekly plan is written on the whiteboard in the dining room. There is a pictorial weekly activity at a glance chart and all activities are recorded in the individual care file. One health and social care professional said in their survey “I am aware that service users engage in a number of activities and the home encourages regular reviews to ensure clients wishes are met as much as their finances will allow”. Another health and social care professional said in their survey “the home has a very good activities programme”. People spoke about attending drama classes in Grays and a “Can Do Group” in South Ockenden. The Can Do Group has been set up by Batias (an independent advocacy service in Essex and Thurrock) and South Essex Partnership University NHS Foundation Trust (SEPT) and is a social inclusion group for people with learning disabilities. Two people living in the home are attending Basildon College studying computers, another person is studying health and beauty and another person is studying digital photography and movie making. When spoken with two people living in the home said that they had just returned from a holiday with a local club and that they were looking forward to another holiday to Butlins holiday camp in Bognor Regis in two weeks time. The manager said “£20 per person per week is allocated from the fees to contribute towards their annual holiday”. The home’s first holiday will take place in a fortnight and people living in the home said they were excited about it and that staff will be going with them. People spoken with said that the staff encourage them to maintain relationships with their friends and families and one person told us how much they enjoyed their regular trips to the local social club, another said that they regularly go home and visit their family and that their family and friends often visit them at the home. The manager said in his AQAA “we have a family and friends contact sheet that staff members on duty fill up and leave comments regarding the visits”. The daily notes contained detailed information about each of the visits that were entered on the contact sheets. There were comments from relatives in the compliments book saying how pleased they were with the service and that they enjoyed the birthday parties that had been held for people living in the home. The menu is devised on a weekly basis, generally on a Sunday after lunch and A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 14 people living in the home decide what they want on the menu for the following week. People have access to a range of colourful photographs of different foods to assist them in their choice. People spoken with said that the use of pictures was helpful and that it made it easier for them to make their choices. There was a range of food in the home and the nutrition records showed that people were provided with a health balanced diet of their choosing. The dining room is pleasant and provides sufficient space for all of the people living in the home to dine together if they wish to do so. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal care in a way that suits them and their health care needs will be fully met. The home’s medication policy and practice will protect people from the risk of medication errors. EVIDENCE: People said when spoken with that the staff assists them in a way that they prefer to be helped and that the staff treats them well with dignity and respect. One person said “I choose when to go to bed and when to get up and when and what I want to eat”. The support plans showed that most of the people living in the home required minimal support with their personal care and they clearly identified where more support was required. One health and social care professional said in their survey “They show respect to the service users and I think they do have the service users’ best interests at heart. One staff member said in their survey “respect and dignity is always taken into account A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 16 and we give people choices in everything they do”. The care plans that we looked at were divided into three separate folders, one of which was specifically for health records. There were copies of health related letters such as those from GP’s, consultants and behaviour therapists. The manager said in his AQAA “we support our service users to involve other healthcare professionals, when they require professional advice, to help them to take control and manage their own health care”. “We also provide support to our service users to attend their appointments with their GPs, Consultants, Nurses, Dietician and other healthcare professionals”. The records showed that people had attended regular health care appointments and the outcomes together with any actions were recorded. The health records showed that charts had been fully completed for various areas such as weight, menstrual, behaviour and trips/falls. There was information in a separate folder regarding swine flu and staffs are asked to read, sign and date to confirm that they had done so. The home uses a monitored dosing system for its medication and we carried out a random check of the medication and its corresponding medication administration sheets (MARS) and all was found to be correct. All staff that administers medication has had medication training and the administration sheets that we looked at were correctly completed showing when people had not taken their medication; they also used the coding and explained the reasons why. There were PRN protocols for all as and when prescribed medication and they showed, why, how and when it was to be taken. The medication policy was last reviewed on 25/2/09 and staff are asked to read it and sign and date it to confirm that they have done so. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know that their concerns will be dealt with and that they will be protected from harm and abuse. EVIDENCE: The complaints policy has been recently reviewed; it is in two different formats, both versions contain pictures and words and one is in an easy read format making it accessible for people using the service. The manager said in his AQAA “we have a system in place that makes it easy for our service users and other key people to raise their concerns or register complaints if they wish to do so. We explain the comments and complaints procedure to all of our service users using their preferred method of communication”. People spoken with confirmed that the manager fully explained the complaints procedure to them and one person said “I feel confident that the manager would sort any complaint out for me”. Another person said “I know that if I make a complaint it will be dealt with”. The homes abuse policy has been recently reviewed and it contains all of the relevant information including the need to refer any suspicion of abuse to the A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 18 Local Authority. All staff has had training in safeguarding adults and when spoken with one staff member described the actions they would take if they suspected any form of abuse. The actions they described corresponded with what was required of them in the homes abuse procedure. The manager has a copy of the Southend Essex and Thurrock Safeguarding Adults Guidelines and one staff member said when spoken with that they were familiar with these. We looked at a random sample of the cash and cash transaction records belonging to people living in the home and we found them to be accurate and up to date. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, comfortable safe environment. EVIDENCE: We looked around the building and found that it was in a good state of repair; each of the rooms are a good size and contain adequate storage facilities. All cupboards with “keep locked” signs on were locked and there were signs on a cleaning cupboard warning people not to enter without authorisation as it was a hazardous area. All of the rooms that we looked at contained many personal items and staff said that people choose their soft furnishings and colour schemes. One person spoken with said “I love my room, it has every thing that I need in it and I chose my own things”. One health and social care professional said in their survey “the house is well maintained and their A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 20 standards are of high quality”. The records showed that repairs were carried out in a timely manner. All of the furniture and fittings are modern and of a good quality and they are kept clean by the people living in the home with support from the staff team. The manager said in his AQAA “service users are always encouraged to keep their home clean and tidy. Some service users have developed a routine to clean their rooms on a regular basis and keep the home tidy but some are taking their time to develop such routines but do it with the right support from the staff”. One person spoken with confirmed that they regularly dust and clean their room and another said that they were “not too keen on cleaning”. The home was pleasant, clean and hygienic. A M Care Home Ltd DS0000071579.V377131.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, 33, 34, 35, 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. People are cared for by a competent, well-trained and supervised staff team, who are safely recruited. EVIDENCE: All of the staff has achieved an NVQ level 2 in care and five staff members have achieved their NVQ level 3. We observed staff working together with people living in the home and they communicated well, they appeared interested in what people were saying and responded to them in a positive way. One staff member said when spoken with “we have a good relationship with the people living in the home and with other health professionals that are involved in people’s care”. One health professional said in their survey “the staff are helpful and polite, show interest and understanding, do their best when providing service to clients and visitors”. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 22 The staff duty roster is prepared by the manager on a monthly basis and it showed that there have been sufficient staff on duty to meet the needs of the people living in the home and that sufficient staff are scheduled to work in the future. The roster was clear and it identified who was on call; it contained a key to explain any abbreviations. Staff spoken with said that they were happy with the roster and that the manager was helpful and flexible if they needed any changes made to their planned duty roster. We looked at three of the staff files and each of them contained the information required under the regulations, which included completed application forms, two written references, satisfactory criminal records bureau checks (CRB) and information relating to the persons induction. The manager said in his AQAA “all our staff are recruited using a thorough recruitment procedure and they have shown that they are commited to their job roles”. Staff spoken with confirmed that the recruitment process was thorough. Each of the staff files that we looked at contained certificates of training that included safeguarding adults, fire safety, medication, health and safety, moving and handling, food hygiene, first aid and infection control. There were certificates to show that all of the staff has had training in more service specific subjects such as understanding mental health, communicating with people with learning disabilities and challenging behaviour. One staff member said in their survey “A M Care is a small and new organisation but I have found out so many helpful things through the care training that I have received”. Another staff member said “the training is really good; I have had lots of training this year”. AM Care Home has been operational since January 2009 and the staff files that we looked at were those of staff that had been employed between January and March 2009. The manager showed us copies of each member of staffs probationary records that covered their first six months supervision sessions. There were further records on each of the staff files that we looked at confirming that supervision takes place and the manager said that these were planned to take place at six weekly intervals. A M Care Home Ltd DS0000071579.V377131.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, 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well run home that is run in their best interests. EVIDENCE: The manager is experienced and has managed other care homes prior to managing A M Care Home; he has achieved an NVQ level 4 in care and the registered managers’ award. The manager regularly updates his practice and has recently attended training in health and safety, fire safety, moving and handling, food hygiene, first aid, challenging behaviour and communicating with people with learning disabilities. One member of staff said in their survey A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 24 “we have a very good manager who gives us the opportunity to be involved in all sorts of the care work including administration”. Quality Assurance questionnaires have been given to people using the service as part of the home’s quality assurance process. The manager said in his AQAA “we have made available a comments and complaints book for our visitors to use and leave feedback. We take the feedback as an opportunity to improve and adapt any reasonable suggestion that will help making our care home a safe place to live and work”. The comments and complaints book included positive comments from the relatives of people living in the home. One health professional said in their survey “the service is very committed to its service users. They take care to ensure the service user has the best possible life. Their communication with the service users is excellent and they always work in the service users best interests”. One staff member said in their survey “the home delivers good quality care to the service users”. We checked a random sample of safety certificates and they were all in place and up to date. There were risk assessments in place for all areas of environmental risks to ensure that staff worked safely; most of the staff team have had infection control training. There was a detailed fire risk assessment and all of the fire records were up to date and regular fire drills take place. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 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 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 X 3 X X 3 X Version 5.2 Page 26 A M Care Home Ltd DS0000071579.V377131.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. 1 Refer to Standard YA1 Good Practice Recommendations It is recommended that the manager keeps his Statement of Purpose and Service User Guide under regular review to ensure that they contain up to date information about the service. A M Care Home Ltd DS0000071579.V377131.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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