Care Home: Ashburnham Road, 95

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What the care home does well Residents, a visiting relative and a professional expressed a good level of satisfaction with respect to the quality of care and support offered at 95 Ashburnham Road. Their views including those of staff have been included in the report. The assessments carried out before people are admitted to the home are good. Care plans are detailed and the six monthly and annual review systems ensure that the resident`s identified needs are addressed and unmet needs, closely monitored. Social and recreational activities to suit the taste and preference of residents are being facilitated; thus maintaining a good level of stimulation. Relationships between the staff and the residents were positive. They demonstrated a good awareness of the identified needs of each person in residence. We saw that staff were very polite, helpful and caring towards the residents. The meals provided are of a good quality and residents like them. Menu Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 planning takes place daily and residents are fully involved in this including shopping and cooking, as appropriate. The training needs and future development of staff are being identified and addressed. NVQ training for staff has been given a high profile; staff are therefore well equipped with the skills and knowledge to provide a good quality service for residents. Care and staff management systems are being implemented to good effect. This means that the residents benefit from a home that is well run, by a manager who is very clear to staff on how residents should be treated. What has improved since the last inspection? The previous inspection carried out in October 2008 left a number of requirements. There is evidence to indicate that these have been addressed resulting in an improved standard of care and safety for residents, and training for staff. Care plans have been updated, in order to clearly identify the care intervention required to ensure consistency in service delivery. All areas of risk identified in the care plan documentation have been risk assessed. Risk assessments therefore show the level of risk posed to the resident. Arrangements are in place to ensure the safe storage and labelling of foods. Temperature control valves have been fitted to all hot water taps in the home, so that hot water temperatures do not exceed the specified safety limits. This means that residents are protected from accidental scalding. The staffing arrangements have been reviewed to ensure sufficient staff are available to deliver the identified care programme for each resident. This has also enabled the manager to work supernumerary to the team, thus focusing her attention on effective implementation of care and staff management systems. The manager has taken remedial action so that all staff receive specific training to include mental health and drug misuse awareness. A system has been introduced, in the form of an annual survey, to seek the views and experience of residents, their representatives and other stakeholders, with a view to improve the quality of service delivery to its residents. The fire authorities have been consulted on fire practices at the home. This ensures the safety of the residents and the staff team.Ashburnham Road, 95DS0000014989.V378596.R01.S.docVersion 5.3 What the care home could do better: There are two recommendations arising from this report that relate to National Minimum Standards. They are seen as good practice and therefore, should be addressed. The contract/terms and conditions should be signed by the resident and their representative. This would demonstrate that the resident and their representative are being placed at the centre of the decision making process. The review minutes should include the signature of the resident and their representative, as well. This would demonstrate their participation at reviews and to an extent, their agreement with the content of the minutes. Key inspection report CARE HOME ADULTS 18-65 Ashburnham Road, 95 Luton LU1 1JW Lead Inspector Neil Fernando Key Unannounced Inspection 27th November 2009 10:45 Ashburnham Road, 95 DS0000014989.V378596.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. Ashburnham Road, 95 DS0000014989.V378596.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 Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Ashburnham Road, 95 Address Luton LU1 1JW 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) 01582 481589 F/P 01582 481589 bertha.kamuna@advanceuk.org Advance Support Ltd Mrs Bertha Kamuna Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2008 Brief Description of the Service: Advance Housing and Supported Living is a voluntary organisation that provides homes in the community for people with learning disabilities and mental health needs. 95 Ashburnham Road residential home accommodates up to 4 adults with mental health needs. The accommodation is a three-storey building. It is situated in a residential area of Luton. It offers all single bedrooms and residents are encouraged to personalise their rooms. A pay phone, 3 bedrooms, bathroom and toilet facilities are located on the second floor. The top floor is used as the staff sleeping room. The ground floor offers a bedroom, lounge/diner, toilet, a kitchen and the manager’s office. The office is accessed via the kitchen next to the utility room. A modest size garden is available to the rear of the property, which is well used by residents during the warmer season. The home is within walking distance of the park, shops, pub and a bus stop. Luton Town centre is approximately three miles from the home. A copy of the service user’s guide and the last inspection report from the Commission is available at the home, for prospective residents and visitors to read. The fee charged is £600:60 per resident, per week. Ashburnham Road, 95 DS0000014989.V378596.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 stars. This means the people who use this service experience good quality outcomes. We, the Care Quality Commission, undertook this unannounced key inspection of this home on 8 October 2009, the last having occurred on 8 September 2008. We spoke with 3 residents, 1 visiting relative and 1 professional, the manager and 2 care staff members. The visit also provided an opportunity to observe staff care practices; medication administration was checked and a range of documents the home must keep, was viewed. We also undertook a brief tour of the home. At the time of the visit, there were 4 people in residence including 1 person at hospital, with no vacancy. We have received the AQAA (Annual Quality Assurance Assessment - a document, which gives the manager the opportunity to tell us how well outcomes are being met for people living in the home); it provides good details about the service. We have also received surveys from 3 staff. The manager was available throughout the inspection. What the service does well: Residents, a visiting relative and a professional expressed a good level of satisfaction with respect to the quality of care and support offered at 95 Ashburnham Road. Their views including those of staff have been included in the report. The assessments carried out before people are admitted to the home are good. Care plans are detailed and the six monthly and annual review systems ensure that the residents identified needs are addressed and unmet needs, closely monitored. Social and recreational activities to suit the taste and preference of residents are being facilitated; thus maintaining a good level of stimulation. Relationships between the staff and the residents were positive. They demonstrated a good awareness of the identified needs of each person in residence. We saw that staff were very polite, helpful and caring towards the residents. The meals provided are of a good quality and residents like them. Menu Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 6 planning takes place daily and residents are fully involved in this including shopping and cooking, as appropriate. The training needs and future development of staff are being identified and addressed. NVQ training for staff has been given a high profile; staff are therefore well equipped with the skills and knowledge to provide a good quality service for residents. Care and staff management systems are being implemented to good effect. This means that the residents benefit from a home that is well run, by a manager who is very clear to staff on how residents should be treated. What has improved since the last inspection? The previous inspection carried out in October 2008 left a number of requirements. There is evidence to indicate that these have been addressed resulting in an improved standard of care and safety for residents, and training for staff. Care plans have been updated, in order to clearly identify the care intervention required to ensure consistency in service delivery. All areas of risk identified in the care plan documentation have been risk assessed. Risk assessments therefore show the level of risk posed to the resident. Arrangements are in place to ensure the safe storage and labelling of foods. Temperature control valves have been fitted to all hot water taps in the home, so that hot water temperatures do not exceed the specified safety limits. This means that residents are protected from accidental scalding. The staffing arrangements have been reviewed to ensure sufficient staff are available to deliver the identified care programme for each resident. This has also enabled the manager to work supernumerary to the team, thus focusing her attention on effective implementation of care and staff management systems. The manager has taken remedial action so that all staff receive specific training to include mental health and drug misuse awareness. A system has been introduced, in the form of an annual survey, to seek the views and experience of residents, their representatives and other stakeholders, with a view to improve the quality of service delivery to its residents. The fire authorities have been consulted on fire practices at the home. This ensures the safety of the residents and the staff team. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 7 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. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 4 and 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. The home has a variety of information to assist the prospective resident decides if it is where they want to live. The pre-admission assessment of needs ensures that they can be fully met on admission.. EVIDENCE: There are 4 adults accommodated in the home including a resident currently receiving hospital treatment. There has been one new resident moving in the home during the week of our visit. Two residents and a visiting relative we spoke with said that they have been given a copy of the service user’s guide and an information pack, which they find helpful. The home has an admissions procedure which is being followed when a new resident moves in. Care files for 3 residents show that a satisfactory preadmission assessment of needs has been completed in each case. We learn from staff members that the prospective resident has the opportunity to visit the home for a cup of tea, a meal or over night stays until a decision Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 10 could be made about whether they could live at the home or not. This is because of the challenging behaviour experienced by people who live at this home could sometimes mean that even if individual needs could be met, this would not be in the best interest of people already living at this home. Overall, evidence shows that the home is careful to only offer a place to the resident whose needs and aspirations it can meet. Records show that each resident has a copy of their individual contract on their respective case file containing the terms and conditions of residence, as stipulated in the National Minimum Standards for Homes for Younger adults. It is noted that the license agreement did not reflect the signature of the resident in one case and the relatives, in two others. It is recommended that the contract/terms and conditions should be signed by the resident and their representative; this would demonstrate that the resident and their representative are being placed at the centre of the decision making process. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 9, and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living at the home receive the support they need to make decisions about how they wish to lead their lives. EVIDENCE: The AQAA states ‘The organisation has a comprehensive policy and procedure and training program re: developing Person Centred Individual Plans and Risk management assessments with each Service User’. The care plans for three residents were seen. Each includes good details of the resident’s personal care needs and of their likes and dislikes. They contain Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 12 detailed assessments including physical, personal and health care, culture and religion, and social and recreational needs. The staff members spoken to said that the care plans give them the information that they need to provide appropriate care for the people who live in the home. There is good evidence to indicate that the residents are fully involved in planning and decision making in respect of their daily lives and activities. The key worker has monthly meetings with their key resident and monthly summaries are prepared of relevant occurrences. The manager and staff team are responsible to review each resident’s care plan every six months; these have been completed as appropriate. There is also an annual review, which is undertaken by the care manager from the supervisory authority. Review minutes reflect the name and signature of the key worker. It is recommended that the review minutes should include the signature of the resident and their representative as well; this would demonstrate their participation at reviews and to an extent, their agreement with the content of the minutes. Each case file examined has a risk assessment in place. The manager and staff spoken with said that these are reviewed and updated as required. Residents said that they are aware that staff members maintain records about them on an ongoing basis. The issues around confidentiality and security of records have been explained to residents and their relatives. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: Standards 12, 13, 14, 15, 16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are involved in a range of activities to meet their individual needs and preferences. EVIDENCE: The home actively encourages residents to pursue a range of activities and to be involved in the day to day running of the home as much as possible. Individual activities are recorded in care plans. Residents have active social lives with trips to pubs and restaurants, shopping, walks and day trips to the coast. Indoor activities that occur with some regularity include board games, reading newspapers and magazines, television and DVD’s, arranging photos albums, preparing snacks and entertaining visitors. One resident also attend a day service. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 14 Residents are actively encouraged to remain in contact with family and friends and there is no restriction regarding visiting the home. ‘I go out with my girl friend twice a week’, said one resident. On the day of the inspection, we spoke with one visiting relative; he said that ‘I am able to visit my brother at any time and staff are always welcoming’. Residents have chosen to hold keys to their bedrooms and main entrance door. Staff members and other residents only enter rooms when invited. Residents are able to spend time alone if they wish or in the company of other residents and staff. Staff members respect residents’ right to live as they like in their own space. Residents own rooms seen during the inspection were neat and tidy. They are able to continue cultural and religious beliefs and customs and staff spoken to confirm that they would always respect residents’ wishes and feelings The residents are fully involved in the planning of menu; people take it in turns to assist in the preparation of meals with staff’s support. If someone wants to eat something different from the menu, they are able to so. The menu was viewed and offered a variety of choice and is devised to meet residents’ individual needs and tastes. People spoken to said they are very happy with the food available to them. ‘I am able to eat whatever I want’, said a resident; ‘I enjoy preparing snacks with help’, reflected another person. Takeaway nights are also organised frequently. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 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): Standards 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good quality health and personal care is provided and recorded in great detail within the care plans. EVIDENCE: The AQAA tells us, ‘The organisation policy and procedure outlines a robust system for ensuring that service users physical and emotional needs are met and includes Health Action Plans which are created with the assisstance of service users and external agencies’. Within the individual plans, evidence is available to show that people using the service have been consulted about how they choose to receive the support they need. All four people living in the home are able to manage their own personal care needs, but they need varying levels of supervision and support. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 16 The people accommodated at 95 Ashburnham Road receive regular checks from community dentists, opticians and chiropodists and all are registered with a local GP practice. Visits to the GP and other health professionals are recorded in the individual’s files. All staff administer medication and they have received the necessary training. One of the people living in the home continues to administer his own medication. Appropriate risk assessment is in place and this is reviewed as necessary. Medication administration records viewed are in good order. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 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): Standards 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures available and training in place ensure that residents are protected and safe. EVIDENCE: The AQAA states, ‘Service users are provided with information on what constitutes Abuse and Harassment via their Support Files and are provided with accessible information on how to raise concerns or make a Complaint. This is reinforced regularly at House Meetings’. The service has the necessary complaints policy in place in accordance with the standards. The complaints log was viewed during the inspection. No complaints have been recorded since the last inspection and the manager clarified that no complaints have been received by the home. However, there is good evidence to indicate that residents are supported to make any concerns known at their monthly meetings, one to one meeting between the resident and their key worker and the monthly summaries prepared by the key worker. Three residents and one visitor spoke to us during the inspection, and as indicated earlier were more than happy with the support residents receive; Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 18 they also stated that they knew who to speak to if they have any concerns regarding any aspects of the service. The service has the necessary protection of vulnerable adults’ policy, which is linked to the local authority procedures. The contact information to use in the event of an incident is available in the staff office. All staff have received appropriate training on safeguarding of vulnerable adults. There has been one safeguarding matter arising since the last inspection. Evidence shows that appropriate action was taken. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 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): Standards 24, 25, 26 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides the people living there with a homely, comfortable and safe environment. EVIDENCE: There were no issues noted in the property and maintenance continues on a routine basis. On the day of the visit, a high standard of cleanliness was evident and the home was tidy. There were no unpleasant odours noted. Communal areas of the accommodation are homely and have a comfortable feel. Since the last inspection, temperature control valves have been installed on all hot water taps in the home, in order to protect people from being scalded. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 20 Throughout the home there is evidence that people using the service are involved in planning decoration. All rooms seen were decorated and furnished to a satisfactory standard and reflected the taste and preference of the person living in them, as far as possible. Residents are offered a key to their own room. All 3 residents spoken with said they are happy with their bedrooms and are consulted on the decoration and furniture for their room and communal areas. There was no health hazards noted. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 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): Standards 32, 33, 34, 35 and 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. Staff are appropriately trained and supervised to ensure that the care and support needs of residents are met. EVIDENCE: Information available from staff, residents and duty rota for a period of one month shows that the day and night staffing arrangements are satisfactory. An on-call facility is shared by the managers of all 5 Advance Support homes in Luton; this means there is always a manager available on call for advice and support, in the absence of the home manager. Residents spoken to said that staff are available when they need them. ‘I have worked with staff at this home for over 2 years and I have found them to be very cooperative; never had a problem with any staff’, said a visiting professional. There are 5 members of care staff working at this home. 4 staff hold an NVQ (National Vocational Qualification) level 3 in care and 1 member is currently Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 22 undertaking training in a professional social work course. This means that the home has already achieved a ratio of 80 of staff with NVQ Level 3. Staff files viewed show that they have completed a variety of courses including Medication, Safeguarding of vulnerable Adults, Mental Health, Stress Management, Working with Alcohol and Drug users, Risk Assessment, Suicide and Self-harm and Mental Capacity Act. The personnel recruitment files for 2 staff were scrutinised. Each contained evidence that appropriate references and checks had been undertaken before they began their employment. 1 file had a CRB certificate and the other, a letter from the head office to confirm that CRB certificate had been received for this staff member. All staff members receive formal recorded supervision from the manager. Both staff spoken to expressed a good level of satisfaction in respect of their supervision. ‘I am happy with my supervision and it’s good’, said a staff. Residents expressed satisfaction with respect to staff’s support they receive – ‘Staff are very good and they are very helpful and always polite’ reflected a resident. Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 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): Standards 38, 39, 40, 41 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents get the right support from the home because the manager runs it well, with an open approach that makes them feel valued and respected. EVIDENCE: The manager tells us in the AQAA, ‘To ensure that services are managed well with good leadership and meet the needs of service users’. The manager has been managing this home since June 2007; she became the registered with the Commission since February 2008. She holds the Registered Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 24 Managers Award and is also a social work Practice assessor with a local university. Evidence indicates that she is managing the home well. The manager receives monthly supervision from her line manager. Two staff spoken with reported that they are happy with the management support they receive. ‘The manager is always available for advice and support’, said a staff member; ‘We could raise any issues or concerns freely with the manager’, said another member. The manager has developed a quality assurance audit to ensure that the quality of service can be improved for the residents. The annual survey was completed in May 2009; the manager is aware that a copy of the published survey report must be sent to the Commission. Monthly visits have been carried out by a manager from one of Advance Support homes within the Luton area, to ensure that appropriate standards are maintained; reports on these visits are available at the home. Records viewed are noted to be satisfactory. Policies and procedures are in place, which are being implemented to good effect. Health and safety including hot water temperatures, fire risk assessment, fire drills, regular alarm and emergency lighting tests are taking place. Evidence shows that staff have received mandatory training including health and safety, thus ensuring the safety of residents. Ashburnham Road, 95 DS0000014989.V378596.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 X 4 3 5 2 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 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 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 X 3 3 3 3 3 X Version 5.3 Page 26 Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc 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. Refer to Standard YA5 Good Practice Recommendations The contract/terms and conditions should be signed by the resident and their representative. This would show that the resident and their representative are being placed at the centre of the decision making process. The review minutes should include the signature of the resident and their representative as well. This would demonstrate their participation at reviews and to an extent, their agreement with the content of the minutes. 2. YA6 Ashburnham Road, 95 DS0000014989.V378596.R01.S.doc Version 5.3 Page 27 Care Quality Commission Eastern 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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