Care Home: Cartref House

What the care home does well The premises are suitable for the care of residents. Residents are helped to lead an active life. Members of staff receive good training and support from the owner organisation to help them meet the support needs of residents. Care plan records reflect the needs of residents and their aspirations. These contain extensive information about how residents are progressing, aims of care identified by staff and agreed with residents (where this is possible), their health requirements and risks associated with their daily living and activities. The service provides a good structure for residents who are considering the next steps towards greater independence. Options are available within the group for realising this target. Each resident has a range of opportunities for progressing their education and leisure, employment and social skills. What has improved since the last inspection? The AQAA refers to ongoing efforts to provide residents with an audio version of key documents. It states that "recording has continued at our local studio onto CD format and we are hopeful that completion of this will be in the near future. Thereafter we will begin investigating the possibility of providing video Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 format to provide service users with a greater understanding of Cartref House and its services". The AQAA suggests that the staff group intend to continue to develop even more sophisticated ways of encouraging residents with communication difficulties to contribute more effectively. " A number of training sessions have been delivered to address perceived short-falls in staff performance and these are set to be reviewed on an annual basis. Also we have devoted additional training resources in helping the team to better understand and work with the issues of autistic spectrum disorders (ASD), those with personality disorders and self-harming conditions". The AQAA outlined how staff awareness of lifestyle issues has been raised through training, staff meetings and coaching sessions. It also indicated that weekly menu meetings have been re-introduced for residents to ensure they have contributed effectively. Changes have been made over the past six months to improve medication procedures, a revised medication system that has in the opinion of support workers reduced the likelihood of errors, more frequent medication audits and a tracking system for medicines taken out of the premises and for PRN. What the care home could do better: This report contains no requirements or recommendations. Key inspection report CARE HOME ADULTS 18-65 Cartref House Cartref House 22 London Road Sittingbourne Kent ME10 1NA Lead Inspector Eamonn Kelly Unannounced Inspection 6th May 2009 11:00 Cartref House DS0000023921.V375246.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. Cartref House DS0000023921.V375246.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 Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cartref House Address Cartref House 22 London Road Sittingbourne Kent ME10 1NA 01795 412231 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) care@cartrefhomes.co.uk Cartref Homes UK Ltd Collette Mawson Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2007 Brief Description of the Service: The website www.cartrefhomes.co.uk defines the objective of the service as providing residential services for young adults with learning disabilities who may also present with challenging behaviours, mental health difficulties and other special needs but who aspire to more independent living. The website describes how the intention is to focus on transitional work - moving service users towards greater skill levels and competence in preparation for moves from residential care into more independent living models. Cartref House provides accommodation on three floors with bedrooms situated on the first and second floors. It gives support for up to 6 people with learning disabilities with, as described above, emphasis on assisting them to move towards a more independent life style. The premises are situated close to shops, bus and train routes and other local amenities. Information about fees, services and facilities may be obtained from the manager and these are also described in a written guide to services. Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means that people who use the service experience good quality outcomes. The inspection took place on 6th May 2009. It comprised discussions with the manager, three support workers and five residents at the premises. Care practices were discussed and most parts of the premises were visited. Some records were seen during the visit principally those addressing the personal and healthcare support of residents. The Commission received an annual quality assurance assessment (AQAA) from the manager. This provided good information about how residents are currently supported and how the service is being developed. The previous report from 2007 and the Commissions annual service review of 2008 were checked as part of this inspection. The evidence of the inspection visit and that contained in the AQAA (annual quality assurance assessment) indicated that significant progress is being made in the interests of resident welfare and comfort and towards meeting the overall objectives of the service. This report contains no recommendations or requirements. What the service does well: What has improved since the last inspection? The AQAA refers to ongoing efforts to provide residents with an audio version of key documents. It states that recording has continued at our local studio onto CD format and we are hopeful that completion of this will be in the near future. Thereafter we will begin investigating the possibility of providing video Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 6 format to provide service users with a greater understanding of Cartref House and its services. The AQAA suggests that the staff group intend to continue to develop even more sophisticated ways of encouraging residents with communication difficulties to contribute more effectively. A number of training sessions have been delivered to address perceived short-falls in staff performance and these are set to be reviewed on an annual basis. Also we have devoted additional training resources in helping the team to better understand and work with the issues of autistic spectrum disorders (ASD), those with personality disorders and self-harming conditions. The AQAA outlined how staff awareness of lifestyle issues has been raised through training, staff meetings and coaching sessions. It also indicated that weekly menu meetings have been re-introduced for residents to ensure they have contributed effectively. Changes have been made over the past six months to improve medication procedures, a revised medication system that has in the opinion of support workers reduced the likelihood of errors, more frequent medication audits and a tracking system for medicines taken out of the premises and for PRN. 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. Cartref House DS0000023921.V375246.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 Cartref House DS0000023921.V375246.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): 1-6 People using the service experience excellent quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Residents have their individual aspirations and needs assessed before they enter residential care. Prospective residents and their representatives are given information in a variety of ways to help an informed choice to be made. EVIDENCE: The AQAA (annual quality assurance assessment) prepared by the manager to assess the current service to residents and to identify areas for improvement states that efforts are being made to encourage residents to move towards a more independent way of living. This is in line with the aims of the service as outlined in its website and statement of purpose. The information available to potential new residents and their representatives has been updated. Advocates are also able to obtain information about the service and other associated services provided by the group from a website. The evidence from resident files seen during the inspection was that careful consideration is given during the time when an admission is being considered. Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 9 This includes carrying out a range of activities involving the potential resident, advocates, medical practitioners and care managers. Following this, a series of observations are carried out to enable staff to compile a care plan and up to date risk assessments. From the examples of records seen and individual profiles discussed, these are subject to constant amendment as the needs of the resident are assessed over time and the corresponding care plan and risk assessments are refined. Each resident is provided with a contract that outlines the main aspects of the responsibilities of both parties. The AQAA refers to ongoing efforts to provide residents with an audio version of key documents. It states that recording has continued at our local studio onto CD format and we are hopeful that completion of this will be in the near future. Thereafter we will begin investigating the possibility of providing video format to provide service users with a greater understanding of Cartref House and its services. Cartref House DS0000023921.V375246.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): 6-10 People using the service experience excellent quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Residents are helped to make decisions and to express themselves as part of developing their confidence and quality of life. EVIDENCE: Each resident has an individual care plan formed from original and subsequent assessments of their needs. They are encouraged to make their own decisions and choices. The manager and senior support worker provided an insight into how this is being achieved. Care plans outline the support needs of both residents and relate to all areas of their lives. A support worker explained how the staff team have the skills and ability to support and encourage residents to be involved in the ongoing development of their plan. They use a variety of ways to help them Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 11 communicate their aspirations and difficulties. New communication methods are being implemented to assist residents and staff. From the evidence of individual profiles discussed, it was clear that members of staff have a good knowledge of the types of support residents need and, from the evidence of the excellent support plans seen, the staff team are succeeding in helping residents exercise choice and make plans for the future. Some residents have begun to make realistic plans for the future and all have increasingly independent lifestyles with agreed levels of staff support. Residents are supported to take reasonable risks to allow them to participate in a range of activities. Risk assessments within care plans indicate how relevant risks are assessed and kept under review. Care plans are kept up to date and focus on how residents develop their skills and have their future aspirations recognised and addressed. The examples of risk assessments discussed address safety issues whilst aiming to maintain good qualities of life for residents. The AQAA suggests that the staff group intend to continue to develop even more sophisticated ways of encouraging residents with communication difficulties to contribute more effectively. A number of training sessions have been delivered to address perceived short-falls in staff performance and these are set to be reviewed on an annual basis. Also we have devoted additional training resources in helping the team to better understand and work with the issues of autistic spectrum disorders (ASD), those with personality disorders and self-harming conditions. Cartref House DS0000023921.V375246.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: 11-17 People using the service experience excellent quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Routines and activities developed with each resident give them opportunities to exercise preferences on a day-to-day basis. They are helped to take part in activities they enjoy and to be a part of community life. EVIDENCE: The AQAA outlines the areas discussed during the inspection visit relating to how significant efforts have been made by the staff team during 2008 and 2009 to improve the lives of residents. It describes how regular resident/staff meetings take place where, for example, activities are discussed and plans are made for additional ones. Each resident has an agreed full weekly timetable of activities and efforts are made to enable these to be carried out. Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 13 The AQAA refers to how members of staff work towards ensuring that activities are age appropriate, appropriately accessible for residents with particular challenges and reviewed so that they are in step with changes agreed during residents meetings or progressive changes to routines agreed for their individual benefit. Current activities include visits on the bus to visit family members, trips to the local pub for a meal, music and activity sessions, 1-1 with staff support to go to the local town and places further away. Each resident has his/her bedroom maintained in a way they prefer and they receive differing levels of staff support in keeping their rooms safe and well maintained. A number of residents kindly provided an opportunity for a visit to their bedrooms. Records and charts maintained showed how residents are encouraged to complete daily and weekly tasks within their home, for example, cooking, cleaning and clothes washing. Care plan records indicate how residents have different plans relating to meals, meal times and preferences. Examples were discussed where relatives were involved in the preparation and review of care plans. There was a great deal of evidence that daily routines are flexible to suit the different needs of residents and of how residents are helped in keeping touch with family and friends. Where a resident was settling in to a new environment at the time of the inspection visit, observation records were maintained to enable skills to be determined, to see how the resident coped with new rules and to check the outcome of how risk assessment procedures. Examples showed how good communication and observation methods are leading to realistic changes in how some residents see their future within supported living frameworks. There is a varied menu and examples of how residents are included in meal preparation and planning were witnessed during the inspection. The AQAA stated that there is emphasis on providing balanced meals that reflect individual taste and preference as well as healthy eating. Importantly all meals are selected, shopped for, prepared and cooked by service users with staff support. Additionally this is incorporated into their care plans / teaching targets as appropriate. The AQAA outlined how staff awareness of lifestyle issues has been raised through training, staff meetings and coaching sessions. It also indicated that weekly menu meetings have been re-introduced for residents to ensure they have contributed effectively. Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 14 Cartref House DS0000023921.V375246.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): 18-21 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Residents receive good physical, emotional and personal support. They are protected by procedures for administering medication. EVIDENCE: The evidence from care plan records and discussion of individual profiles of five residents indicated that residents receive good healthcare support. This includes access to GPs and NHS healthcare facilities. Regular appointments are seen as important and systems are in place to ensure they are not missed. The home arranges for health professionals to visit residents at home when necessary. There is good quality planning and support for residents. The care plans seen during the inspection had good information for carers in the event of having to deal with episodes of various conditions associated with individual residents. Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 16 Support workers have a high level of awareness of resident’s emotional needs and they explained how they help them to retain individual identity. The staff supervision process, from the two examples seen, contribute to helping staff in this important area of practice. Medication is stored in a locked cupboard and MAR sheets are updated when medicines are administered. Procedures have been reviewed and the manager is confident that current procedures are effective. Two residents keep their own medicines and, before they are enabled to embark on this course of action, they must be seen to be able to do so competently and follow specific rules. Resident’s individual plans record their personal and healthcare needs and outline how these are being met. Members of staff ensure that personal support is flexible, consistent and able to meet the changing needs of residents. They provided examples of how they know and respect resident’s preferences. The home has a detailed policy, procedure and practice guidance to help staff when caring for residents with degenerative or complex physical or mental health conditions. Members of staff receive practical support and advice and have opportunities to discuss any areas of anxiety and concern they may have about how residents are developing or otherwise. There was evidence that the staff team reviewed all aspects of residents personal and healthcare needs over the past six months. This was evidenced through discussion of residents profiles and how they are moving towards better realisation of their preferences and expectations. Also the extensive nature of care plan and healthcare records and AQAA reflections contributed to this conclusion. The AQAA outlined how changes have been made over the past six months to improve medication procedures, a revised medication system that has in the opinion of support workers reduced the likelihood of errors, more frequent medication audits and a tracking system for medicines taken out of the premises and for PRN. Part of this tracking system was seen during the inspection. The AQAA refers to how risk assessments have been updated and to how they form part of the individual care plans. Progress has been made in using plain language in care plans that suit residents individually and that includes pictures and photographs. Information is outlined on how staff training in health matters and individual health action plans are now seen to be giving residents more control over their own health with the support they need. Cartref House DS0000023921.V375246.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 made this judgement using a range of evidence including a visit to the service. People at the home know that they can complain or comment about the support they receive and that their complaints and comments will be taken seriously. They are protected from abuse by procedures practiced by staff. EVIDENCE: The service has a complaints procedure and residents are encouraged to express themselves in ways that members of staff understand. An example arose in that a resident is helping other residents and members of staff with communicating through maketon. No complaints have been received since the previous inspection visit. Members of staff said they welcome comments from residents and their supporters about how care and support is provided. Policies and procedures for safeguarding adults are available to all members of staff and give specific guidance to those using them. Staff working at the service said they know when incidents need external input and who to refer the incident to for guidance. The manager said that support workers understand local authority procedures for Safeguarding Adults and, if necessary, would attend SA meetings or provide information to external agencies. Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 18 The Commission is notified of incidents that occurred and reflection on these is reportedly used as part of quality assurance measures for the protection of residents. The recruitment procedure contains the checks (including CRB checks) necessary to help contribute to the protection of residents and all members of staff receive training for their responsibilities under current POVA arrangements. The AQAA stated that all members of staff are aware of the rights of residents and of how their interests must be identified and promoted. It outlines how the companys quality assurance system focuses on issues consistent with current care standards with emphasis on making residents quality of life progressively better. It also highlighted the fact that current stable management conditions have had a positive effect on residents and on the staff team and the evidence of the inspection supports that conclusion. Reference was also made to staff guidance on relevant aspects of the Mental Capacity Act and how essential procedures might be affected. Cartref House DS0000023921.V375246.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 made this judgement using a range of evidence including a visit to the service. The premises are suitable for the support of residents. EVIDENCE: The AQAA stated that essential refurbishment is carried out routinely. Bedrooms are suitable for the needs of residents. Each person has their own bedroom that is well decorated and personalised with their own belongings. Bedroom doors are lockable; people can have their own keys and are able to invite others to visit their room when they wish. A conservatory provides additional communal space for residents and staff. Residents are able to use the garden easily. The premises are clean throughout; soap dispensers and paper hand towels have been placed in the laundry and communal washing areas to promote Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 20 infection control. Residents use the laundry facilities as part of agreed household tasks and to give them the skills they need where they might be able to aim towards moving to more independent living. A member of staff explained how they canvass residents views and involve them in discussing potential changes to the premises including colour schemes in bedrooms. A declaration is made in the AQAA that all necessary checks are carried out and that the necessary certificates are in place. Cartref House DS0000023921.V375246.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): 31-36 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Residents are in the care of members of staff that are skilled in meeting their support needs. EVIDENCE: Staff files for all staff in the group are kept at the nearby office and the range of checks carried out during recruitment was checked during a more recent inspection. The Commission is satisfied that residents are protected in a number of ways including the required recruitment procedures. The manager of each service is involved in these procedures. Managers, for example, ensure that CRB checks are taken up in every case according to the records seen. All new members of staff have suitable induction and foundation training based on standards recommended by Skills for Care. According to the AQAA, most support workers are trained to NVQ Level 2 or above and others are completing NVQ training. Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 22 There was evidence on this occasion that a stable management system is in place and that the staff team is addressing the needs of residents. From two examples of staff files seen, it was evident that the manager undertakes formal supervision in a planned way with all members of staff. The stated purpose is to identify practice standards relevant to the needs of residents and staff and to progress the objectives of the staff team and aims of the group. The AQAA included an analysis of the effectiveness of recruitment and staff development procedures. From the documents seen, it is possible to conclude that all relevant checks are carried out, there is a process for involving some residents in the recruitment process and support workers receive good guidance and on-going support. The AQAA, for example, stated that in addition to the statutory training provided for every member of staff specific training to meet the needs of each resident is given. Examples of the knowledge and skill levels needed by staff were discussed during the inspection and it was clear that all staff receive specialist training as needed according to the changing needs of residents. Cartref House DS0000023921.V375246.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): 37-43 People using the service experience good quality outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Residents live in an environment that is well managed. Residents and members of staff are benefiting from improvements in the way the service is conducted. EVIDENCE: The AQAA stated that policies are gradually all being updated with more accessible formats being introduced. Quality assurance questionnaires have been developed and are completed by residents, their families and health/social care professionals with an annual report compiled from the results. The manager said that managers in branches of the organisation and Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 24 the registered responsible person for the overall service make assessments of this feedback and use it to progress the quality of the service. Other procedures include reviews of care plans, staff meetings and regular 1-1 supervision. The service has a development plan and environmental risk assessments were regularly conducted to ensure the safety of service users. Risk assessments for individuals form a key part of support in place for residents. Residents referred to how key workers take a special interest in, for example, keeping care plans updated and individual residents involved in this. The medication system has been thoroughly reviewed by the manager and improvements made for the safety of residents and benefit of staff. This includes how some residents are enabled to keep their medication, the rules they must follow, how procedures are followed to ensure that essential medication is taken and how medication is handled when residents are off the premises sometimes for longer periods of time. During the inspection visit, the manager described how consideration is given to carrying out health and safety procedures affecting the safety of premises and individuals. The manager is working to improve services and to provide an ever-improving quality of life for residents and is aware of current developments both nationally and by CQC. Care plan and healthcare records seen indicated that there are sophisticated procedures for meeting the needs of respective residents. Declarations are included in the AQAA about the required checks to premises and associated procedures and safety certificates. The manager has the experience and qualifications to run the care home in line with current legislation and standards. The AQAA outlined how this experience is being deployed for the benefit of residents. From evidence seen during the inspection and from references in the AQAA, the use of a person centred approach is improving the lives of residents and giving support workers an effective framework to carry out their work professionally. The provision of the service by the manager and staff team is complemented, according to members of staff, by the support received from other parts of the company and from the registered responsible person for the wider service. Cartref House DS0000023921.V375246.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 4 2 4 3 4 4 4 5 4 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 4 4 4 4 4 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Version 5.2 Page 26 Cartref House DS0000023921.V375246.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. Refer to Standard Good Practice Recommendations Cartref House DS0000023921.V375246.R01.S.doc Version 5.2 Page 27 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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