Care Home: Delos Community Ltd, 109 Great Park Street

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What the care home does well Great Park Street is a warm and friendly home and you will be made welcome during your visit. Bedrooms viewed were clean and pleasant and contained personal items. Support plans are developed with people who use the service and person centred. People are involved with decisions made about them, the home and in developing their support plans. People using the service are supported to be as independent as possible. Support workers are available to assist people in meeting their personal and healthcare needs. Your privacy will be was respected. Support workers are trained and have good support. Most information is available in easy read documents. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 People using the service feel safe. What has improved since the last inspection? Medication Administration Records are now completed fully and monitored by management. Risk assessments for people living in the home must are individualised to minimise the risk to them. The care plan must include all the information required and are demonstrate that people using the service are supported to make choices. The service has copies of regulation 26 monitoring visits made by managers of the organisation. Safe Guarding procedures operate fully within the service. The service no longer uses volunteers to undertake work shifts at the home. Incidents are reported to CQC in accordance with regulations. Support workers have completed all required basic training. Quality assurance monitoring is undertaken and is available in report format for people who use the service and their representatives. What the care home could do better: Ensure that all medication stored within the original packaging has accurate stock records to ensure that people using the service are protected. Key inspection report CARE HOME ADULTS 18-65 Delos Community Ltd, 109 Great Park Street 109 Great Park Street Wellingborough Northants NN8 4EA Lead Inspector Judith Roan Key Unannounced Inspection 8th October 2009 3:00 Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.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. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.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 Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Delos Community Ltd, 109 Great Park Street Address 109 Great Park Street Wellingborough Northants NN8 4EA 01933 222532 01933 677881 info@delos.org.uk www.delos.org.uk Delos Community Limited 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) Post Vacant Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may only admit service users aged 18-65 No person falling within the category MD may be admitted to the home unless that person also falls within category LD - I.e. dual disability 21st September 2008 Date of last inspection Brief Description of the Service: 109 Great Park Street is situated in a residential area close to the town centre of Wellingborough. The home is also known as The Frogpond and is one of four registered homes within easy walking distance of each other, supported by a Head Office and Day Centre in separate premises. Further support services are provided within the organisation for those moving on into a more independent lifestyle. The collective facilities are known as the Delos Community where residents are known as members. The home provides personal care and support for up to three members whose primary care needs are due to having a learning disability. The environment is that of a family house. Members have their own bedrooms but there are no en-suite facilities. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.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. The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people who use the service and their views of the service provided. This process considers the services capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting one person who uses the service and tracking the care they receive through review of their records, discussion with them, the support staff and observation of care practices. The homes previously registered manager who remains working for the Delos Community also completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CQC. A new manager has been appointed and will be making an application to become registered with CQC. This was an unannounced inspection, which took place over the course of the afternoon and early evening. The fees start at £650 and increase depending on the needs of the person using the service per week. This fee does not cover the full cost of individual holidays arranged, personal toiletries or clothes. The Statement of Purpose and Service Users Guide are available in accessible formats from the Manager. The most recent inspection report is available through the home or on the Care Quality Commission’s website. What the service does well: Great Park Street is a warm and friendly home and you will be made welcome during your visit. Bedrooms viewed were clean and pleasant and contained personal items. Support plans are developed with people who use the service and person centred. People are involved with decisions made about them, the home and in developing their support plans. People using the service are supported to be as independent as possible. Support workers are available to assist people in meeting their personal and healthcare needs. Your privacy will be was respected. Support workers are trained and have good support. Most information is available in easy read documents. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 6 People using the service feel safe. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.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 Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.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. People considering using the service will have their needs assessed to ensure that these could be met. EVIDENCE: It is evident from case tracking the records that a through assessment of need was undertaken at the time of admission to ensure that individual needs could be met. The assessments seen as part of the case tracking were detailed and gathered information from the individual person making the application, their family, previous placements and the funding authorities. People spoken with confirmed that they had visited the home prior to moving in and had stayed overnight. Pictorial information is available for prospective users of the service that require an easy read format. The person case tracked was very satisfied with how their introduction to the service was carried out. Individual files held contracts made with the provider and the person receiving the service. An additional contract is made with the funding authority. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 9 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. Support plans are person centred and demonstrate full involvement of people using the service. EVIDENCE: Support plans are in place for people who use the service and are reviewed on a regular basis or as required. Regular forums in which the support needs of individuals are reviewed ensure that there is continuous development. In case tracking and discussion with the person case tracked there was confirmation that they were fully involved with the development of their support plans and the reviews. Evidence demonstrated that required care plan approach meetings are held to meet the legal requirements in support of people who are a mental health section leave. The files also held documentation stating agreed legal status and timescales. Good record keeping ensures that information is shared appropriately. Confidentiality is maintained with all support workers understanding the Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 10 importance of keeping personal information in secure files. A locked filing cabinet is available and people using that use the service are fully assured that their information is handled sensitively. All people using the service have access to their files and confirmed that support plans. Personal centred plans are in place and enhance support plans in use at the service. Work continues in making the information easy to use and accessible. The outcomes for people using the service support are positive and that needs are being met within the systems in place at the home. In discussion with support workers it was evident they are very knowledgeable about the needs of the people they support. In reviewing the files and in discussion with individuals using the service it was evident that they were being assisted to develop their skills and participate in everyday activities that they previously were not able to achieve. Learning is achieved by the consistent approaches used by support workers and people using the service having access to a broad spectrum of daily living activities. The person case tracked said that they have had good experiences at the home and that the support was meeting their needs. Risks within activities are considered on an individual basis and plans are made to minimise these for each person. Files contained comprehensive risk assessments related to an individual’s activities. In viewing files it was not easy to identify the needs of individuals and to establish the priority as there was a significant amount of information. In discussion with the previous manager they confirmed that plans were being reviewed and updated to make them more streamlined and easy to use. People using the service are encouraged to be as independent as possible with appropriate support. In this way people using the service are included within activities and not excluded because of any behaviour that may arise. The AQAA confirms that ‘Members are consulted on how they feel about how their home is run. Members have their say on key decisions in the home. Members are actively encouraged to participate in the weekly house meetings.’ People using the service told the inspector said that they were supported well and no one thought they were denied their choices. Discussions with the staff member on duty supported these facts and demonstrated that they were up to date with information about people who use the service. It was evident that people using the service are supported to make decisions about their own lives wherever possible e.g. daily routines, where they want to go on holiday and how their personal needs are met. Regular meetings held record their views on important issues regarding food, holidays, outings etc. Staff said that encouraging people to make informed choices is an essential part of the values of the home. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 11 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. A wide range of personal, educational and social options are available and promote individual development EVIDENCE: Individuals have a weekly activities programme that is updated to take into account of various events and personal choices. New activities are tried out to extend the choices and experiences for each person. Daily routines are agreed with individuals and are flexible. Careful planning is undertaken for all activities to ensure that people who use the service and support workers are protected and enjoy the experience. Experiences are good and varied. It was noted that people attend day services and also have support at home on a one to one basis. Social histories are held on files and provided good information about previous experiences and early life. People using the service confirmed that they had a choice of activities and Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 12 these could be changed easily to meet their needs. The AQAA also supported this fact ‘All members are supported to be part of their local community. Members are supported to access places such as shops, pubs, library, cinema, bowling, swimming, gym, clubs and places of interest. Members are actively encouraged and supported to travel to different locations in the wider community of their chosen location to do personal shopping. A range of day trips and other significant events take place throughout the year.’ People using the service are fully involved with day-to-day living tasks within the home. In discussion with the person case tracked they confirmed that they had prepared the evening meal with support. It was clear that they are happy with their achievements and enjoyed the activity. The teatime meal was freshly cooked and healthy. Individuals are supported to make healthy choices and have a balanced diet, with opportunities to have the occasional not so healthy treat. Support workers have a good understanding of the needs for people who use the service and use the meal times to develop communication skills with each other. Meals were seen to be a very social event at the home. There is much negotiation between individuals so that meal times can be arranged around social activities. The standard of food prepared at the home is high being produced from fresh produce. A food diary is kept to ensure that a balanced diet is provided. Individuals are supported to maintain good communication with families with files detailing information about how contact should be supported. Records supported these activities. People spoken to during the inspection said that we are supported to do what they liked and enjoyed living at the home. There was evidence of leisure activities going to colleges, discos, local pubs etc. Files show details about activities undertaken and holidays taken. Members Meeting notes showed that they have been consulted and trips are planned in the future. Support workers said that the service offers a good choice of social activities and that the home has an informal relaxed atmosphere. The homes location means there is good access to local shops and community facilities. Throughout the inspection the inspector observed positive work with individuals using strategies noted within the support plans in supporting people with their identified needs. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 13 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. People using the service have good support access to health care services but are not fully protected by the record keeping for of medication, which leaves them vulnerable. EVIDENCE: People using the service are supported to have regular health checks and there is evidence on files that healthcare appointments are made. The AQAA also confirms that people using the service have their health care needs met. ‘All members are supported to access all healthcare facilities and to attend all medical appointments. Members are supported to attend their medication reviews. All members have an “emergency grab sheet” for any admissions to hospital. Monthly summary sheets have just been put in place to monitor each member’s health and well being. The team has a strong relationship with the local community team. Their input is given if needed. Support plans viewed indicate the health care needs of individuals and cover the management of personal care, monitoring weight and medication profiles. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 14 Personal support is provided in a discreet manner, with people using the service preferences being a top priority. Medical profiles for people who use the service have clear information. All medication is stored in a locked facility but no controlled drugs cabinet is in place. A requirement is made for the provider to review their storage facilities in accordance with the change in regulations in 2007. Medication administration records (MAR) sheets have improved and the requirement made at the last inspection has been met. We did observe staff signing for medication before it was taken by the individual and this is not good practice. Medication that is prescribed from St Andrews Hospital is not within the monitored dosage system and is administered direct from the original packaging. The stock records were found to have significant inaccuracies which had been identified in a recent regulation visit but had not been rectified. Support workers receive training in the management of medication and undertake refresher training on a regular basis. The records seen during the inspection show that individual’s are consulted about their medication. Where the service takes on the responsibility of administration individuals sign to give their consent. The AQAA confirms this ‘All members have given written consent for the administration of their medication. Any member wishing to self medicate is trained and supported to do so.’ One person using the service self medicates. All incidents are recorded on file to show how the manager/support workers have reviewed practice to minimise future risks. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 15 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. Practices within the service fully protect people who use the service and ensure that they are listened to. EVIDENCE: The service has comprehensive policies and procedures in relation to handling concerns and complaints. People who use the service were all clear about how to make a complaint saying they would speak with the manager or a member of their family. Support workers undertake abuse awareness training as part of their induction/ foundation training. Several have completed this as part of their National Vocational Qualifications. The inspector checked out their understanding during the inspection. Staff training records were available on site for inspection. The openness of managers and support staff enables people who use the service to feel comfortable if there was a need to make a complaint or express a concern. One person spoke of the fact they had complained about the level of the food budget. They remain unhappy that it has not risen in line with inflation. Management are aware and are investigating the situation. The AQAA confirms that there has been one complaint since the last inspection which has not been upheld. The AQAA also states that ‘All members are issued with an easy to read complaints procedure booklet. The complaints procedure is also included within the service user guide. All members are aware of who they need to speak to if they wish to make a complaint. The member is explained the complaints procedure by their key worker to enable their Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 16 understanding. An easy to read complaints poster is on display in one of the communal lounges. There is a grumbles book for members to record their views and problems in. This is readily available to use when they wish, support is provided for members to record in the book if required. The team leader will review the comments and follow them up with the member.’ In discussions during the inspection it was concluded that people using the service felt safe and that support workers had a good understanding of their role and were aware of policies and procedures. Recruitment procedures ensure that support workers working at the service are security checked with files supporting that enhanced Criminal Record Bureau disclosures have been undertaken. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 17 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. The home provides a warm family setting with individual space that is well maintained clean and hygienic. EVIDENCE: The home provides a clean, hygienic, safe and well-maintained environment. The atmosphere is calm and relaxing. A garden situated at the rear of the building offers good outdoor space where people can sit and relax in good weather. Bathrooms, bedrooms and communal areas are well maintained and decorated. Bedrooms viewed were personalised, containing personal possessions, photographs, ornaments, and reflected each individuals personality. People spoken with during the inspection stated they are very happy with their bedrooms. The home provides an environment that reflects normal family life. There are adequate rooms to enable everyone to have their own personal space. All people using the service have single rooms with good access to family style bathrooms. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 18 Communal areas are used for joint activities and each bedroom has sufficient room for personal hobbies. People using the service are supported in maintaining their rooms to a high standard of cleanliness and safety. It was evident during the inspection that daily living tasks are completed with people using the service and that no activity is undertaken without their involvement. There is a family size kitchen that leads off the lounge. The dining area can accommodate all of the people living at the home where meals are eaten as a family. The manager states within the AQAA that ‘The home has a planned maintenance and renewal programme in place for the forthcoming year. Members are involved in developing that list. Members are involved and encouraged to choose furniture and redecoration for their bedrooms and communal areas. Members are supported to personalise their rooms as they wish, within fire and safety regulations. All members are actively involved in the running of their home. They are supported as needed with doing their own laundry, ironing, making drinks, snacks and cooking, promoting their independent skills. Members are enabled to have their own front door key, if they so wish. Members can also have a lock on their bedroom door if they choose to. All staff receives infection control and food hygiene training. The home is 5* rated by the local environmental health department. The home uses the food standards agency ‘safer food-better business for caterers’ file, this is filled in on a daily basis.’ Records seen during the inspection support that required health and safety checks are carried out. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 19 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. Staff skills and recruitment practices ensure that the needs of people who use the service are supported and that they are protected. EVIDENCE: Delos has a thorough recruitment procedure and files seen confirmed that required employment checks (application form, two references, criminal records bureau disclosures and interviews that involve people who use the service) had been undertaken. People that use the service are involved with the recruitment and selection of staff that work for Delos. Records show that the support worker team have undertaken a range of training to support the needs of people that use the service. Through observation during the inspection they showed that they had a range of skills to support individuals and were proactive in developing everyday living skills. Support workers are offered a range of opportunities to train. Of the staff team of seven, six people have National Vocational Qualification (NVQ) at level two or above. Support workers have access to a wide range of topics – the Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 20 Person Centred Planning system which identifies service user’s individual needs, Communication, Risk Assessment, Fire, and Food Hygiene, Training records are kept within individual staff files held at the main office. A copy of staff training was made available for the inspection. The AQAA and staff met confirmed that new support workers are assisted to ‘undertake the Learning disability qualification (LDQ) induction and foundation qualifications within six months of starting employment with Delos. This based on the skills for care recommendations.’ A support worker spoken to had a good knowledge safeguarding and infection control measures and were committed to providing a good service. They said that they felt well supported by managers. The AQAA states that ‘Team meetings are held every three weeks. A regular agenda is set and records are kept of the minutes. All staff have the opportunity to contribute towards the agenda.’ Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 21 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. The service is person centred and effectively managed in the best interest of people who use it. EVIDENCE: The previously registered and new manager have effectively managed the home since the last inspection and have demonstrated that it is run in the best interests of people who use the service. There was good feedback from people who use the service and support staff about the role of the manager. The new manager needs to ensure that they make a timely application to become the registered manager with CQC. There are several internal meetings within the service that focus on person centred care and enable people to voice their views and choices. All meeting Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 22 have clear and comprehensive records. The AQAA confirms that the views of people using the service are listened to by ‘Members have annual questionnaires to fill in asking for their views and opinions of the service they receive. The members are supported to fill them in either by the Quality assurance manager or with family members. The questionnaires are presented in a service user friendly format. The results are presented in graphs as a whole and passed to the registered manager. The registered manager then follows up any issues. In addition, a members (service users) forum called “hear- say “has been up and running since November 2008, which is chaired and run by the members, with our Quality assurance manager acting as facilitator. The “hear-say” meetings have been a great success to date.’ The organisations senior managers review the service through the regulation 26 visits and on a monthly basis. In addition monitoring forms are completed to ensure that the service develops and maintains a quality assurance system. All meetings at the home are recorded and demonstrate how the views of people using are fed into the ongoing review. Throughout the AQAA there was reflective commentary about the future development needs of the service and shows that the management team are proactive. The provider has undertaken all health and safety checks required. Clear records of all checks are well maintained. The AQAA also confirms the checks undertaken. Delos has robust financial checks of personal monies that require records of receipts, running balances. Monies are checked to ensure they are correct. Health and Safety Policies and Procedures are in place support workers are aware of these. Induction training ensures staffs knowledge and understanding of these. Health and safety record checks were seen during the inspection and meet the required under regulations. Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 23 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000039664.V378008.R01.S.doc 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Version 5.3 Page 24 Delos Community Ltd, 109 Great Park Street 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. 1. Standard YA20 Regulation 13 Timescale for action Ensure that all medication stored 30/11/09 within the original packaging has accurate stock records to ensure that people using the service are protected. The manager must review how 31/01/10 controlled drugs can be safely stored. To ensure that they and meet the new regulations that came into force in 2007. Requirement 2 YA20 13 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 Delos Community Ltd, 109 Great Park Street DS0000039664.V378008.R01.S.doc Version 5.3 Page 25 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@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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