Care Home: Delos Community Ltd, 34 Finedon Road

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What the care home does well Information is available in easy read/ accessible formats. Support plans are clear and person centred. Staff are well trained and have good communication skills. Support with personal care respects dignity and choice. A range of daily educational/leisure activities are available. People feel safe living at the home. Health & Safety system are in place. You will be listened to and views are taken seriously. The home is comfortable and well maintained. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 The service is well managed. What has improved since the last inspection? Members forum has been set up within the residential service. Members have been involved in the recruitment process for staff. Members have new style comprehensive care plans in place. The support team are putting together a social activities folder in order to encourage access to the wider community. We have begun putting together person centred plans with the use of power point.(a visual based computer programme) `Ideas, Suggestions and Grumbles` book in place for members to use. The residential service has a team of bank workers in place which reduces the need to use agency staff. What the care home could do better: The service is reflective and continues to develop the service. Key inspection report CARE HOME ADULTS 18-65 Delos Community Ltd, 34 Finedon Road 34 Finedon Road Wellingborough Northants NN8 4EB Lead Inspector Judith Roan Key Unannounced Inspection 5th June 2009 08:00 Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.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. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.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 Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delos Community Ltd, 34 Finedon Road Address 34 Finedon Road Wellingborough Northants NN8 4EB 01933 225197 01933 677881 mikebrennan@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) Lucy Panter Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 7th June 2006 Date of last inspection Brief Description of the Service: 34 Finedon Road is situated in a residential area close to the town centre of Wellingborough. The home is also known as Avonlea 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 seven members whose primary care needs are due to having a learning disability. The environment is that of a large family house. Members have their own bedrooms but there are no ensuite facilities. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.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 3 star. This means the people who use this service experience excellent 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 two people who use the service and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The Inspector also received questionnaires completed by relatives and staff. The questionnaires provided very positive feedback of the quality of care and service. The homes registered manager also completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CSCI. The inspection was unannounced and was undertaken during the morning and lasted 5 Hours. The fees range from £621 per week. What the service does well: Information is available in easy read/ accessible formats. Support plans are clear and person centred. Staff are well trained and have good communication skills. Support with personal care respects dignity and choice. A range of daily educational/leisure activities are available. People feel safe living at the home. Health & Safety system are in place. You will be listened to and views are taken seriously. The home is comfortable and well maintained. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 6 The service is well managed. 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, 34 Finedon Road DS0000039665.V375758.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 Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.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): People using the service experience excellent quality outcomes in this area. Accessible information and well planned admissions enable individuals to make an informed choice and have a positive experience when moving into the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Good information is available for people enquiring about the service that is to be produced in various formats’ according to peoples needs. It is evident from case tracking the records that a through assessment of need was undertaken by the homes manager at the time of admission to ensure that their individual needs could be met. Information was gained from the person applying for admission where applicable, care managers, health care professionals and families. The assessments seen as part of the case tracking were detailed and enabled the manager to make a decision as whether the needs could be met within the service. This information is updated with ongoing work especially in relation personal and social developments. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 9 The AQAA completed by the manager confirms the admissions process by saying that Our service user guide is user friendly – uses symbols and photo’s. Where a positive choice has been made to join the home we implement a transitional plan offering practical and emotional support to enable a positive and welcoming experience.’ All people being admitted to the service have an opportunity to visit the home on several occasions prior to a trial stay. Careful plans are made with staff at the service to ensure that the person receives additional support in the initial weeks. During this time support workers are working with the new person to develop their support plan. Individual’s 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, 34 Finedon Road DS0000039665.V375758.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): People using the service experience excellent quality outcomes in this area. Support plans are person centred and demonstrate full involvement of people using the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Detailed support plans are in place for all people who use the service and are reviewed as required. Regular forums in which support needs of individuals are reviewed ensure that there is continuous development. In addition to the support PCP’s (personal care plans) have been developed that are in accessible formats. During the inspection several people demonstrated how these plans are used to enhance their involvement. Good record keeping ensures that information is shared appropriately. Confidentiality is maintained with all support workers understanding the importance of keeping personal information in secure files. All people using the service have access to their files and confirmed that support plans had been developed with them. The outcomes for people using the service support are Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 11 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. A new support worker informed the inspector that they had worked alongside another experienced worker until they has demonstrated that they were competent and confident in meeting individual’s needs. Feedback from families all confirmed that they pleased with how their family members are being supported and progress made. 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. Risks within activities are considered on an individual basis and plans made to minimise these for each person. Files contained comprehensive risk assessments related to an individual’s activities. 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. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.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: People using the service experience excellent quality outcomes in this area. A wide range of personal, educational and social options are available and promote individual development. We have made this judgement using a range of evidence, including a visit to this service. 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. Since moving into the service all of the individuals that the inspector spoke with had developed communication skills and were fully involved in activities outside of the home. In case tracking one person evidence was found on how support workers communicate plans for the following day. A pictorial day planner was in place and support assisted the person to prepare it for the following day. The planner was up to date and enabled the individual to use it for interaction. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 13 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 several people attend college and work opportunities are being sought. People using the service are fully involved with day-to-day living tasks within the home. Each person takes it in turn to prepare the evening meal with appropriate support. Individuals choose a meal from a selection they all enjoy. The process supports people to experience all aspect of the meals preparation from checking out supplies, purchasing the food and cooking the meal. In observation support workers enable people to carry out tasks and help only when necessary to demonstrate and develop the skill. It was clear that individuals were positive about their achievements. Throughout the inspection the inspector observed positive work with people using the service with strategies noted within the support plans. The meals are freshly cooked and healthy. At lunchtime individuals in the home at the time have sandwiches or a snack of their choice. Those attending day opportunities prepare a pack up the evening before. 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. The AQAA confirms that ‘The home uses the Food Standards Agency’s ‘safer food – better business for caterers’ file. Support workers fill this in on a daily basis.’ Families commented on how good the communication has been with them and that the registered manager and the team of support workers always kept them informed. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. People using the service are positively supported to access local and specialist healthcare services. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People using the service users are supported to have regular health checks and there is evidence on files that healthcare appointments are made. The AQAA confirms that people using the service ‘The support team use a person centred approach whilst providing personal care. The home has a good link with the Community Team for People with Learning Disabilities. Their input is given if needed. Health Action Plans are in place for all members. These are regularly reviewed and all members have had OK health checks. These are now provided by individuals GP surgeries. Each member is supported to review their essential lifestyle plan outlining personal preferences whilst receiving support.’ Personal support is provided in a discreet manner, with people using the service preferences being a top priority. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 15 Medical profiles for people who use the service have clear information. All medication is stored in a locked facility and records were well maintained. A controlled drugs cabinet is to be installed so that the service is meeting the new regulations that came into force in 2007. All incidents are recorded on file to show how the manager/support workers have reviewed practice to minimise future risks. The manager and staff at all levels have a good understanding of risk assessment processes which is underpinned by promoting independence, choice and autonomy. All incidents are reported to the CQC with there being positive communication between the inspector and registered manager and outcomes. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. Practices within the service fully protect people who use the service and ensure that they are listened to. We have made this judgement using a range of evidence, including a visit to this service. 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. The AQAA states that ‘There is an easy to read complaints poster on display in one of the communal lounges. There is an ‘idea’s, suggestions and grumbles’ book within the home. This is a book that members can record their views or problems in. The Registered Manager regularly reviews the comments and follows them up with individuals. It’s important to recognise individual’s issues before they develop into formal complaints. Members also have the opportunity to raise any issues or problems with others and staff at the weekly house meetings. All issues are recorded and addressed.’ The inspection confirmed that all of the above systems are in place. Information about how to make a complaint is available in accessible formats for people who have communication needs. The complaints procedure is also available in an audio format and on power point (A visual computer programme). Support workers undertake abuse awareness training as part of their induction/ foundation training. Several have also completed this as part of their National Vocational Qualification. The inspector checked out their Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 17 understanding during the inspection. The open approach of the registered manager enables people who use the service to feel comfortable if there was a need to make a complaint or express a concern. There have been no complaints since the last inspection. Over the past few months the staff team at the service has managed a safeguarding incident. Response was actively taken to support the person with their personal safety. Risk assessments have been updated to provide guidance for support workers. Referrals were also made for support from health care professionals. The Registered manager notifies CQC of incidents that affect the well being on any person using the service. The recruitment practices at the service are robust and ensure that all required employment checks are completed. Detailed records are stored at the services head office with copies of essential documents being available at the home for inspection. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. The home provides a warm family setting with individual space that is well maintained clean and hygienic. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is a large converted house unit that is decorated and maintained to a good standard. There are adequate rooms to enable everyone to have their own personal space. Several communal areas are used for joint activities and each bedroom has and sufficient room for personal hobbies. The AQAA states that ‘Members are involved in choosing furniture and redecoration colours for their bedrooms and the communal areas. Members are supported to personalise their rooms as they wish, within fire and safety regulations. All members are involved in keeping the house to a clean standard. The support team have daily and weekly cleaning schedules to adhere to. Members also have a daily jobs rota to follow.’ Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 19 Individual bedrooms seen were personalised, comfortable and well maintained. There is a family size kitchen that is large enough for people who use the service to assist or sit comfortably and be part of meal preparations. The garden provides areas for relaxation when the weather is fine. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. Staff skills and recruitment practices are of a high standard, ensuring that the service is person centred and that the needs of people who use the service are fully supported. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The support worker team have a sound knowledge base about the needs of people that use the service. Through observation during the inspection the staff team showed that they had a range of skills to support individuals and were proactive in developing everyday living skills. Support workers also demonstrated that they have the skills to communicate effectively with all people using the service. Communication was seen to be natural and inclusive of the people that use the service. Support workers are available in sufficient numbers to support the needs, activities and aspirations of people using the service in an individualised and person centred way. The service is innovative and shows a high level of awareness of staffing levels needed. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 21 The service is highly selective, with the recruitment of the right person for the job being more important to the filling of a vacancy. People who use the service are involved in the recruitment of staff and receive training and support to do this. New support workers all have an induction programme which they work through with the registered manager. The AQAA confirms that ‘All new staff have to complete the Learning Disability Qualification when they begin employment. The induction is completed within 6 weeks and the foundation within 6 months.’ Management prioritise training and facilitate support workers to undertake external qualifications beyond basic requirements. The home has internal developmental training, to complement formal training as part of an ongoing training plan. Support workers are offered a range of opportunities to train. All support workers either hold or are working towards NVQ level at 2 or above. Support workers have regular supervision with the registered manager. They also support each other and share skills and knowledge with colleagues at team meetings. Support workers are clear about their roles and responsibilities. People who use the service and others associated with the service report that staff are very skilled in their role, and the service has quality assurance systems to ensure views are gathered and acted upon. They are able to meet the needs of individuals in a variety of ways. Policies and procedures demonstrates that the provider has a very good understanding of equality and diversity throughout the recruitment, induction and training process. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. Management are proactive in developing the service and ensures that the quality assurance process is reflective and involves people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Registered Manager effectively manages the home in the best interests of people who use the service and the support workers. The manager communicates a clear sense of direction and in discussion demonstrated a sound understanding and application of ‘best practice’ in operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Equality and diversity, human rights and person centred thinking are given priority by the manager who was able to demonstrate a high level of understanding and demonstrate best practice in these areas. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 23 There are several internal meetings within the service that focus on person centred care and enable people to voice their views and choices. The manager provides an excellent role model for support workers and demonstrated a good person centred approach. There is strong evidence that the ethos of the home is open and transparent. The views of both people who use the service and staff are listened to, and valued. The registered manager is developing the services quality assurance system The AQAA states that ‘The service has a several quality assurance systems in place; service user surveys, house meetings, members forum meeting minutes, periodic service review results and Regulation 26 visits.’. During the inspection the registered manager discussed with the inspector the need to include reflection on incidents within the quality assurance process to demonstrate learning and development of the service. It was also recommended that views of staff and health care professionals were included within the annual quality assurance process. Systems are fully developed within the home ensure effective safeguarding and management of money and valuables of people using the service, with good records. People are supported to manage their own money where possible. The provider has undertaken all health and safety checks required. The AQAA confirms the checks undertaken. Health and safety systems are regularly reviewed and updated. Regulation 26 (external review conducted by the provider or a designated responsible individual) visits ensures that systems are checked. The manager ensures that all support workers are trained in health and safety matters. Individual training records reflect this with regular updates planned. Record keeping is of standard and kept securely, with support workers being aware of the requirements of the Data Protection Act. People who use the service have direct access to their records and contribute to them. They are always involved with changes are made and how this information is communicated. The service has a comprehensive range of policies and procedures to promote and protect the health and safety of people using the service and staff. Staff are trained, understand, and consistently follow these. The AQAA confirms the dates that these have been reviewed. Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 24 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 4 3 4 4 4 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 3 32 4 33 4 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000039665.V375758.R01.S.doc 4 4 4 4 4 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 3 3 3 4 X Version 5.2 Page 25 Delos Community Ltd, 34 Finedon Road Are there any outstanding requirements from the last inspection? N/A 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 Delos Community Ltd, 34 Finedon Road DS0000039665.V375758.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands 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. 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