Care Home: Acorn

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What the care home does well There are good aims and objectives within the home to ensure that individuals are encouraged to be as independent as possible and lead the life they choose. Individuals can be confident that they are the focus of the care. There is a good range of activities available to the individual both in the home and the local community. Competent and experienced staff support the individual. What has improved since the last inspection? Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Not relevant as this was the service`s first key inspection. What the care home could do better: Ensure that individuals are protected by competent staff in the event of a fire. Key inspection report CARE HOME ADULTS 18-65 Colour-Lit View 65 Downend Road Fishponds Bristol BS16 5EF Lead Inspector Paula Cordell Key Unannounced Inspection 15th September 2009 09:20 Colour-Lit View DS0000072192.V377652.R01.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. Colour-Lit View DS0000072192.V377652.R01.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 Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Colour-Lit View Address 65 Downend Road Fishponds Bristol BS16 5EF 0117 9085440 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) Top Drawer Properties Limited Lee Michael Janes Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 4. Date of last inspection Brief Description of the Service: Colour Lit View is registered with the Care Quality Commission to provide personal care to four people with a learning disability. The home was registered in October 2008. The first person to move to the home was in July 2009. The registered manager is Mr Lee Janes who has day to day responsibility for the home. The home is privately owned. The home is situated in a residential area of Bristol with good transport links and close to other amenities. The fees are approximately £1,300 per week but this will vary depending on the assessment of the individuals. Colour-Lit View DS0000072192.V377652.R01.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 2 star. This means the people who use this service experience good quality outcomes. This was the first key inspection for Colour Lit View. The service was registered in October 2008 along with the registered manager. A random visit was completed in March 2009 but at this time there were no people living in the home. The first person moved to the home in July 2009. The purpose of this visit was to ensure the home was meeting the National Minimum Standards and the Care Home Regulations and to review the care provided to the individual living in the home. Presently there is one person living at Colour Lit View. The Care Quality Commission has not received any complaints about the service. The visit was planned using information received during the registration process and notifications that affect the well being of the individual(s) living in the home. The visit was conducted over five hours during which records relating to care, staff training and recruitment and health and safety were viewed to ensure compliance with the legislation. Opportunities were taken to speak with the individual living in the home, two members of staff, the registered manager and the owner. An opportunity was taken to look around the home. Structured feedback was given to the senior team leader. What the service does well: What has improved since the last inspection? Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 6 Not relevant as this was the service’s first key 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. Colour-Lit View DS0000072192.V377652.R01.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 Colour-Lit View DS0000072192.V377652.R01.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): 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. Individuals have available information to enable them to make a decision to move to the home. Individuals can be confident that their needs would be assessed prior to moving to Colour Lit View ensuring the home is suitable. EVIDENCE: The home has a statement of purpose and a service user guide. This contained clear information about the service provided at Colour Lit View. This was assessed at the point of registration as meeting the legislation. The service user guide was viewed on this occasion. It was in an accessible format and included photographs and symbols. The senior team leader stated that as new people move to the home this would be made more accessible depending on the skills of the person. A copy was made available to the individual living in the home. Presently there is only one person living in the home. However, from talking with the registered manager and the senior team leader it was evident that they were actively trying to fill the vacancies. The manager clearly described the assessment process and the people the home can support. It was evident Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 9 that the person presently living in the home will be consulted to ensure compatibility. The home has an admission policy and this is included in the statement of purpose. Care documentation seen demonstrated that a thorough assessment had been completed prior to the individual moving to the home. Information was sought from other professionals involved in the life of the person. Further work was being completed in respect of another individual and this was comprehensive. An opportunity was taken to speak with the individual and it was evident that they have settled in well. From observations they had built a good relationship with the staff that were on duty. From records it was evident that the staff had met the individual prior to them moving to Colour Lit View and visits to the home had been arranged as part of the assessment and settling in period. Contracts were in place clearly stating what the service provided and the fees. This met with the legislation. The individual had signed the contract. Colour-Lit View DS0000072192.V377652.R01.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): 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. Individuals can be confident that their care needs will be met in a person centred way. Individuals will be involved in the planning of their day to day care and making decisions about their lives. Individuals are encouraged to be as independent as possible within a risk assessment framework. EVIDENCE: Care records were looked at for the person living in the home. These were informative and focused on the person. As the person has only been living in the home for a period of ten weeks the process of review was discussed with the manager and the senior team leader. It was evident that the individual would be involved in all decisions and the review process. The manager said that care records would be reviewed at least Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 11 once in a six month period or more frequent as needs change. From reading the care documentation in place it was evident that the staff were updating the care records as they were learning more about the person. Staff were knowledgeable about the person and the aims and objectives of the home. The manager said that the plan is for the home to support individuals to move to more independent living as part of their long term goal if that is what the person would like. The person living in the home confirmed that they were involved in all decisions including how they want to spend their time, when to get up and what to eat. The manager said that this will be extended to the other three people as and when they move to the home. Risk assessments were in place ensuring the safety of the individual without compromising their independence. These covered a wide range of activities both in the home and the community. Whilst it was difficult to fully judge the home as there is only one person presently living there, the staff were committed to provide a good level of care based on the aims and the objectives of the service. This included choice, independence and self advocacy. The manager said that staffing would be increased as new people move to the home ensuring that the needs of the individuals are met. Records were held securely. Staff were aware of the confidentiality policy. Colour-Lit View DS0000072192.V377652.R01.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: 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 person living in the home is being supported to be active both in the home and community choosing on a daily basis how to spend their time. A good balanced diet is being offered with a lot of choice being given to the individual living in the home. EVIDENCE: Care records provided information on how the person liked to spend their time. It was evident from the conversations with both the staff and the individual that they were supported to lead a very active lifestyle based on choice both in the home and the community. Whilst there is an activity plan, staff said that this was a rough guide and much of the day to day planning was done by the person and was constantly being Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 13 kept under review to ensure that it remains suitable. The person said that they are supported to go to the gym, swimming, skate boarding and will be attending college courses. They were looking to go Surfing in Devon over the weekend. In addition, activities are being organised in the home to build on skills in relation to independent living including cooking, shopping, budgeting and literacy skills. Records are maintained of the activities offered. The individual confirmed they were active in the home assisting with shopping and household chores. Daily records were maintained of the support offered further, demonstrating the active lifestyle that has been encouraged. The home has a visitor’s policy and a record is maintained of people visiting the home. Information relating to visitors is included in the statement of purpose and the service user guide. Care records provided detailed information about friends and family contact and how the person likes to be supported with this. The menus were viewed. From talking with the individual it was evident they were assisting with the weekly menu and choosing what to eat on a daily basis. Clear records were maintained of the food being made available. The kitchen was well stocked with a range of convenience and fresh food. Colour-Lit View DS0000072192.V377652.R01.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): 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. Individual’s personal and health care needs are being met. Good medication systems are in place to ensure that individual’s are protected. EVIDENCE: Care records included how the person liked to be supported with personal and health care needs. It was recommended that the home develops health action plans in accordance with the government’s white paper “Valuing People”. The senior team leader said whilst the individual has been registered with the local doctor’s surgery there is still a need to register with a local dentist and optician. The home is accessing other professionals where relevant including a consultant psychiatrist and the local community learning disability Team. Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 15 The Care file provided evidence that the person would be supported with their emotional needs. Weekly advocacy sessions are organised to discuss any concerns or anxieties that the person may be experiencing. The care file included information to support the person with challenging behaviour including triggers and diffusing techniques. Staff have received training in supporting people who challenge. Staff spoken with including the manager stated that restraint is only used as a last result and in consultation with other professionals and the individual. The philosophy of the home is that restraint will not be used and other more appropriate approaches would be instigated to prevent episodes of challenging behaviour. The medication system was reviewed. Appropriate storage is in place. Staff have received training in medication in the form of an induction. The senior team leader said that further training will be organised to refresh staff as most have completed this in their previous roles. It would be good practice to develop competence checklists for staff with these being periodically reviewed. Good records were maintained of medication entering the home, the administration and disposal. There is a medication policy in place which covers all aspects of ensuring individuals are protected in respect of the administration of medication and any errors that may occur. Colour-Lit View DS0000072192.V377652.R01.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): 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. Individuals can be confident that their concerns would be listened to and acted upon. Individuals are assured their protection in the event of an allegation of abuse. EVIDENCE: The home has a complaints procedure. This is included in the statement of purpose and the service user guide. The details of the Care Quality Commission need to be updated in respect of contact details and the name as this refers to the previous organisation, The Commission for Social Care Inspection. Presently records relating to complaints are held electronically. It is recommended that all complaints are recorded in a complaint book detailing the complaint, the action taken to address the concern and the outcome. This will ensure that information is accessible to staff and inspection by the Care Quality Commission. The senior team leader said that the home has had two complaints, one from the individual and the other from a neighbour. Both have been addressed. Individuals will be consulted on a weekly basis as part of an advocacy session to ensure they are happy with the care they receive and to make decisions on how they would like to spend their time. During the session key workers will Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 17 talk through any anxieties they may be having. Records are maintained of the session and reviewed by the manager. The home has policies and procedures relating to safeguarding including Whistle Blowing and guidance from South Gloucestershire Council in respect of reporting allegations of abuse. Some of the staff have received training on safeguarding and there is a plan in place for the remainder staff to have this updated. The senior team leader and the manager are planning to complete further training on safeguarding specifically aimed at senior management in October 2009. This would be good practice. Good procedures were in place relating to finances including obtaining receipts. Transactions were being signed by one member of staff. Good practice would be for two staff members to sign financial transactions. The individual was signing some but not all expenditure this should be addressed ensuring a consistent approach. From talking with the senior team leader and reading care documentation that the person was being encouraged to take responsibility for some of their finances within a risk assessment framework with this being increased as the person becomes more confident. Colour-Lit View DS0000072192.V377652.R01.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): 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. Individuals benefit from a home that is comfortable and fit for purpose. EVIDENCE: Colour Lit View is situated in a residential area of Bristol close to local amenities and transport links. It is a spacious detached property situated within its own enclosed garden and is in keeping with the local neighbourhood. The home has been furnished to a high standard and provides a comfortable and homely environment for people who live in Colour Lit View. Individuals have access to a large living room and dining room which opens out on to the kitchen. There is a conservatory to the rear of the property. Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 19 There are four single bedrooms again furnished to a good standard. Individuals will be encouraged to personalise their bedrooms. Two of the bedrooms have ensuite facilities, with one of these being on the ground floor. There is one communal bathroom situated on the first floor. There is a small cupboard area leading off from the dining room which contains the laundry facilities. This was assessed as adequate during the registration visit, noting that the area was fitted with adequate ventilation and the flooring was fit for purpose. All areas of the home were clean and free from odour. Cleaning schedules were in place. The care staff and the individual living in the home complete the household chores. The owner has the responsibility to ensure repairs are responded too. Staff email the request through to the owner. However this does not enable the home to audit the efficiency of the repairs and the response. Good practice would be for the home to maintain a record of repairs including when they have been completed. The home was inspected by the Environmental Health Officer as part of the registration process and assessed as being suitable and fit for purpose. Colour-Lit View DS0000072192.V377652.R01.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): 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. Staffing levels are appropriate to support the person living in the home. Competent and experienced staff support the individual with good communication and support mechanisms being in place. EVIDENCE: Presently the home is occupied by one person. Staffing rotas and conversations with staff and the individual living in the home provided evidence that the staffing was appropriate to meet the needs of the person. The manager said that there is always one member of staff working in the home 24 hours a day. Presently staff provide sleep in cover but this will be reviewed when further individuals move to the home. The plan is that there will be three/two staff working in the home throughout the day and evening and then one member of staff providing either sleep in cover or night cover depending on the assessed needs of the new people. Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 21 From the conversations with the manager it was evident that the philosophy of the home was to provide a personalised package of care for each person ensuring appropriate staffing to ensure that this takes place. Presently the home has three permanent members of staff with a further three members of staff who work bank with the view for them to be more permanent as the home increases in occupancy. Four members of staff records were seen in respect of recruitment, induction, training and ongoing support. Recruitment information was held securely and included an application, notes from the interview, and two references for three of the staff, one member of staff only had one reference but evidence was that this was being chased up. This person had worked previously for the manager. All staff had been subjected to a criminal record bureau check at an enhanced level and this had been obtained prior to commencing employment. The recruitment file was difficult to navigate and would benefit from being better organised as all documentation was kept loose and in no logical order. Records confirmed that staff have completed an induction. The senior team leader said they were looking to introduce the Learning Disability Qualification as part of the induction process. Two staff have already completed the award in their previous roles. This will be followed up at the next visit. The team have experience of working together in another care home. It was evident that much of the training has been provided by their previous employer. The senior team leader said that they were liaising with a training provider to ensure that training is updated in respect of statutory training and training relevant to the needs of the people they will be supporting. A training analysis has been completed identifying what staff have completed and when training is due. Staff training certificates were seen on file. Areas that have been identified include safeguarding, first aid and food hygiene. This will be followed up at the next visit. It was evident from talking with the team leader that there was a commitment to providing ongoing training relevant to the needs of the individuals. Two of the three staff have a National Vocational Award and the third is being enrolled to complete a NVQ at level 2. The senior team lead said this will be extended to all staff that work in the home. There are good support mechanisms in place for staff including monthly team meetings, six weekly supervisions and an open door management style being adopted by the manager and the senior team leader. Whilst this home is in its infancy, it was evident from talking with the senior team leader there is a commitment to ensure that these continue in the future. Colour-Lit View DS0000072192.V377652.R01.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): 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. Colour Lit View is a well managed home where the focus is the individuals. There are good quality initiatives in place involving the person living in the home. Individuals can be assured their safety is maintained. EVIDENCE: Mr Lee Janes is the registered manager for the home. He has many years experience of supporting people with a learning disability and eight of those have been in a management capacity. Mr Janes has completed a National Vocational Award at Level 4, the Leadership and Management Qualification previously know as the Registered Managers Award and has a teaching certificate. Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 23 Staff spoke positively about the manager and the aims and objectives of the home. The staff described an open door approach to management. There are systems in place to monitor the quality of the care provided at Colour Lit View including questionnaires for people who use the service, staff and relatives. In addition there are environmental, medication and training audits. Other areas where it was evident that the quality of the service provided was discussed was at care reviews and team meetings. The responsible individual is also completing monthly quality assurance visits in respect of regulation 26 of the Care Home Regulations. The report was comprehensive and detailed actions the staff should take to address any shortfalls. From talking with the senior team leader and observations the home has addressed the areas identified in the last report. The manager and the provider said that the responsible individual has resigned from the post and the owner will be completing this in future. This has been put in writing to the Care Quality Commission. Policies and procedures were kept in the office and were accessible to the staff team. Staff have signed to say they have read and understood the policies. Staff are also issued with a staff handbook which contains information about their role and key policies and procedures. It was noted that some of the policies need amending to reflect the change in name of the Care Quality Commission and address. Fire records viewed, demonstrated that the equipment was routinely being checked by the care staff and external contractors. Training was in place for fire however less apparent was staff taking part in a fire drill once in a six month period. Two staff, both bank but regularly work in the home have not taken part in a fire drill in the last six months. The home has a dedicated cupboard for chemicals hazardous to health and keep copies of the data sheets and risk assessments. Food hygiene guidelines were in place for staff. Records are maintained for fridge/freezer and food probing. It was noted that the electrical appliances had not been checked in accordance with the legislation. The owner gave reassurances that this would be completed. The senior team leader contacted the Care Quality Commission by telephone confirming that this was being completed and that they had spoken with the Health and Safety Executive. This is good practice and demonstrated a proactive approach to ensuring the safety of the individuals. Certificates were seen in relation to the Landlords Gas Certificate. The Gas Certificate was dated August 2008 however reassurances were given by the Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 24 senior team leader that this had been completed in September 2009 and the certificate was with the owner of the property. Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X 3 3 X Version 5.3 Page 26 Colour-Lit View DS0000072192.V377652.R01.S.doc Na 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 YA42 Regulation 23 (4) a Requirement For staff to complete a fire drill once in a six month period. Ensuring individuals are protected in the event of a fire. 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 YA42 Good Practice Recommendations For the home to ensure that the Landlord’s gas certificate is held in the home. Colour-Lit View DS0000072192.V377652.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission South West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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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