Care Home: Fletton Avenue

What the care home does well The home`s Statement of Purpose and Service User Guide contain text and appropriate pictorial messages about the service. The two people living at the home spoke about the home and gave very clear views that they like living there. One person said it was, "mantastic". They explained to us how they were given choices about a lot of daily routines as well as wishes about travelling and doing the things they were interested in. One person regularly attends football matches and has daily excursions to wherever he chooses. Another person is being facilitated to attend college each day and to gain a greater amount of independence. Choice and respect are part of the service that was observed to be upheld by staff and the acting manager. The home had a friendly atmosphere created by the style and ease of interaction between staff and the two people living there. People engaged with staff in a confident manner. A positive and relaxed atmosphere was seen to be encouraged. The assessment process and the arrangements made for people to move into the home are carefully and comprehensively planned. The needs of all the Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 people likely to be living together are incorporated into this planning. Care plans were detailed and descriptive documents that contained clear statements of choice and aspirations. Individual needs were known to staff who demonstrated they had a good knowledge and understanding of these needs and how to respond differently to individual needs. Safeguarding had been promoted. Staff demonstrated they were able and willing to independently report abuse, should this be necessary. The home arranges adequate training for staff. The management of the home is an open and transparent process. Staff understand their responsibilities and said they felt supported by the acting manager and enjoyed their jobs. The home are aware they must be fully prepared to meet the needs of any person intending to move into the home and how the dynamics of the service could differ if four people were living at the home. There were positive comments made about the home by friends and relatives. Relative`s told us, "I think its great", when they were asked about the care at the home and "they do as much as they can, he goes everywhere and they take him there" when referring to the lifestyle of their son. Another relative said, "they are doing a smashing job. It is better than where he was before". This person stated "the home had even offered me transport home on one occasion". Another close relative said, "the smallness of the service is good" and indicated this home was an improvement on the care that her son had previously experienced. What has improved since the last inspection? This is the first inspection since becoming registered on 18th December 2008. What the care home could do better: The arrangement made for auditing medication should be reviewed, so there is no confusion about when this has taken place. When the home conducts their own monitoring of medication, this should not be recorded on the Medication Administration Record (MAR) charts, so that it does not cause any confusion about the record maintained on this chart. The initial, brief induction that is provided when people commence work should include Safeguarding awareness.Fletton AvenueDS0000073024.V375556.R01.S.docVersion 5.2 Key inspection report CARE HOME ADULTS 18-65 Fletton Avenue 35 Fletton Avenue Peterborough Cambridge PE2 8AX Lead Inspector Don Traylen Unannounced Inspection 28th May 2009 10:00 Fletton Avenue DS0000073024.V375556.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. Fletton Avenue DS0000073024.V375556.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 Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fletton Avenue Address 35 Fletton Avenue Peterborough Cambridge PE2 8AX TBA TBA 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) www.concensusupport.com Consensus Support Services Ltd Nigel Taylor Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Both whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 This is the first inspection since becoming registered Date of last inspection Brief Description of the Service: 35 Fletton Avenue became registered as a care home on 18th December 2008. The building has been totally adapted and extended into a modern care home and is situated on a main route into Peterborough city centre. The building can accommodate up to four people and offers a spacious environment and rooms with full en-suite facilities. Consensus Support Services are the registered providers who provide specialist support services for people with learning disabilities. The fees start at £1700 per week and vary according to the amount of individual support that is required. Inspection reports will be available at the home, or can be viewed on the Care Quality Commission’s website. Fletton Avenue DS0000073024.V375556.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 “two stars”. This means the people who use this service experience good quality outcomes. We visited the home on the 28/05/2009 and started the inspection at 10:00 am and completed our site visit at 16:00 pm. The two people who were living at the home were present for most of the inspection and they spoke extensively to us about their experiences of living at the home. The acting manager and two care support workers and a behavioural specialist employed by the service were also present. We assessed the arrangements for people intending to live at the home and the assessment process and the plans for their care. Observations were made throughout the inspection of the wellbeing of the people living at the home and how staff interacted with them. The lifestyle and choices available to people and their participation in the wider community, was discussed and assessed. The promotion of independence was an aspect of care that was also assessed. Staff recruitment records and staff training records and supervision reports were seen. We talked to people throughout the inspection and during their lunchtime meal (when we were invited by them to share this time). We spoke to three close relatives and asked for their views of the service. The service completed an Annual Quality Assurance Assessment (AQAA) prior to the inspection. What the service does well: The home’s Statement of Purpose and Service User Guide contain text and appropriate pictorial messages about the service. The two people living at the home spoke about the home and gave very clear views that they like living there. One person said it was, “mantastic”. They explained to us how they were given choices about a lot of daily routines as well as wishes about travelling and doing the things they were interested in. One person regularly attends football matches and has daily excursions to wherever he chooses. Another person is being facilitated to attend college each day and to gain a greater amount of independence. Choice and respect are part of the service that was observed to be upheld by staff and the acting manager. The home had a friendly atmosphere created by the style and ease of interaction between staff and the two people living there. People engaged with staff in a confident manner. A positive and relaxed atmosphere was seen to be encouraged. The assessment process and the arrangements made for people to move into the home are carefully and comprehensively planned. The needs of all the Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 6 people likely to be living together are incorporated into this planning. Care plans were detailed and descriptive documents that contained clear statements of choice and aspirations. Individual needs were known to staff who demonstrated they had a good knowledge and understanding of these needs and how to respond differently to individual needs. Safeguarding had been promoted. Staff demonstrated they were able and willing to independently report abuse, should this be necessary. The home arranges adequate training for staff. The management of the home is an open and transparent process. Staff understand their responsibilities and said they felt supported by the acting manager and enjoyed their jobs. The home are aware they must be fully prepared to meet the needs of any person intending to move into the home and how the dynamics of the service could differ if four people were living at the home. There were positive comments made about the home by friends and relatives. Relative’s told us, “I think its great”, when they were asked about the care at the home and “they do as much as they can, he goes everywhere and they take him there” when referring to the lifestyle of their son. Another relative said, “they are doing a smashing job. It is better than where he was before”. This person stated “the home had even offered me transport home on one occasion”. Another close relative said, “the smallness of the service is good” and indicated this home was an improvement on the care that her son had previously experienced. What has improved since the last inspection? What they could do better: The arrangement made for auditing medication should be reviewed, so there is no confusion about when this has taken place. When the home conducts their own monitoring of medication, this should not be recorded on the Medication Administration Record (MAR) charts, so that it does not cause any confusion about the record maintained on this chart. The initial, brief induction that is provided when people commence work should include Safeguarding awareness. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 7 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. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4, People using the service experience good quality outcomes in this area. People are assured their needs are assessed and known by the home before they decide to move there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Two people assessment details were read they contained full and comprehensive details of their needs and their social history. People had been offered a long period of time to visit the home and to explore whether they felt comfortable there. One other person who was considering moving into the home at the time of the inspection had been assessed by a multidisciplinary team and advice and assessment of known and potential risks were being prepared and planned. The acting manager and support staff told us how the needs of people already living at the home would be considered before anybody else moved there. The home has a written Statement of Purpose and User Guide that has text and pictorial information about the service. One person confirmed these pictures were sufficient to inform him about the home. Fletton Avenue DS0000073024.V375556.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): 6,7,8,9, People using the service experience good quality outcomes in this area. People are assured their care is planned and their choices and freedoms are integral to care planning. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care plans are individually written according to people’s needs. People preferences were clearly recorded and demonstrated to be a part of their plan. We spoke to both people living at the home about their plans and what had been recorded. They agreed this was accurate and were aware of these records. They each confirmed their families had been involved in their plans and had informed the home to influence these plans. The plans contained good detailed aspects of an appropriate range of needs and included: communication; diet; medical diagnoses; behavioural traits and specific interventions; prescribed medication; moving and handling; previous history and abilities and preferences. A health contact plan had been recorded stating Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 11 the Health Service professionals who were involved and how to contact these key people. Records of the contacts with health professionals and with social care professionals were kept. Risks had been identified and there were assessments of these risks. These identified risks indicated a clear route for the support to be provided. Nutrition and diet were significant in one person’s plan. Where one to one support was necessary these was clearly recorded. Although, when care staff take people on excursions and are drivers of vehicles, the numbers of staff needed should be precisely stated. The activities that people are involved in are listed and a plan to make these happen was recorded. One person attends college for five days each week and had a clear objective to pursue an employment route. He told us that he wants to work and become independent and eventually move away and live on his own. This goal is an objective of his care plan and was one that staff talked to us about as an aim for this person. The financial arrangement for a person to access and how he controlled his money was recorded. We asked him about this and he confirmed that the plan was correct when we read it to him. One person’s care plan had been reviewed. Interests such as swimming and going to football stadiums for matches and supporting a team were stated. The plans were indexed and clearly written and were neatly maintained in a plastic bound folder. The plans were written as computer based Word documents as well as some parts being hand-written. We discussed with the manager that a plan for managing medication should be recorded in detail to indicate any progress people are making in managing their medication and to reflect what the arrangement is for each person’s medication when they are not at the home. Fletton Avenue DS0000073024.V375556.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: 11,12,13,15,16,17, People using the service experience good quality outcomes in this area. People are assured they have opportunities for personal and social development and that they can undertake activities that have been assessed for risks. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: One person attends college five days a week and had a clear strategy to attain a qualification. He was supported to do this and the home ensured he was taken to college each day in the transport provided by the home. Each week an individual activity plan is written. This is chosen by the person as well as their longstanding arrangements being included. Interests such a going to a monthly disco, going swimming, the provision of a season ticket to regularly watch a local football club had been made. There were plan for each person to have a holiday and we were informed about this by one of the people living at the home. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 13 Regular visits by family are facilitated and in some instances managed by staff. Each person has use of one cordless telephone whenever they wish to use a phone. One person has his own mobile phone. One person has an arrangement to see his girlfriend and this is facilitated by the home who provide transport when he visits her. Inclusion in selecting food and deciding meals is an essential aspect of supporting both people. Both were involved in these arrangements and were fully aware of the food the home purchases and that they can influence the selection of food. Usually one person will accompany support staff when they shop. Both people told us they had plenty to eat and that the food was chosen by them. A lunchtime meal was observed. Two people invited us to spend time with them during their lunchtime meal. This meal was baked potatoes with cheese, or coleslaw, or beans. Specific attention was paid to the amount of calories and the dietary needs of both people. Staff had prepared the meal and choices were made at the last minute about who wanted what. One person explained to us his diet and demonstrated a clear understanding and participation in his dietary planning and decision making. Fletton Avenue DS0000073024.V375556.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): 18,19,20, People using the service experience good quality outcomes in this area. People are assured they will receive personal support as they prefer and support for their emotional and physical health. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care plan records showed that people emotional and behavioural traits were understood and when staff spoke to us they demonstrated their knowledge of emotional and physical needs. One person’s care plans had recorded how the home was safeguarding him and this included emotional and physical support. We asked two people if their care was as they wanted it to be and were asked if staff treated them respectfully. They told us they were helped by staff in the way they wanted. Throughout the inspection there were many instances when staff were approached and asked for their support. Staff responded in a manner that was supportive of each person’s and was balanced with an understanding of individual ability and independence. Two people told us their care was as they wanted it. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 15 People had been considered for managing their medication and in one person case his plan included his wish to understand and manage his medication. He was realistic in that his preference was not possible at the time and was an aspiration he was aiming for. Medication Administration Records (MAR) charts were read and some medication was checked for accuracy of stock held by the home. In one person’s medication record the home’s audit process was recorded on the MAR charts which caused some uncertainty at what time of the day these had been audited. This was discussed with the acting manager who agreed she would ensure these records did not in the future confuse the amount of medication that was held by the home. Medication was safely stored and managed by the home. Fletton Avenue DS0000073024.V375556.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): 22,23, People using the service experience good quality outcomes in this area. People are assured they are safeguarded by the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a suitable safeguarding policy. They keep a safeguarding resource file of information about protecting vulnerable people from abuse and harm. This file included details of the local authority role and a list of essential contacts for reporting an allegation or concern about abuse. When we spoke to staff about abuse they demonstrated they could independently report abuse and knew where to find these detail in the above file that was kept in the office. Two support staff demonstrated they would not hesitate to respond and report any concern if any person was being harmed. All staff had received safeguarding training. One person’s care plans had recorded how the home was safeguarding him. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 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): 24,25,27,28,29,30, People using the service experience excellent quality outcomes in this area. People are assured the home is clean safe and comfortable and they have the good facilities and a spacious modern environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The building has been converted and completely renovated and modernised from a former family residence to a home designed to accommodate four people. The building has been refurbished to a high specification. It consists of an entrance lobby, an office, a dining room, lounge, kitchen, four bedrooms, a laundry and a quiet room. The corridors, doorways and rooms are spacious enough for wheelchairs. There are suitable spacious communal areas. Each bedroom is large and has full en-suite facilities. There are satisfactory lockable storage areas for any hazardous substances. The modern and good sized laundry has two industrial washing machines. Two people’s rooms had been personalised and they told us their rooms were “great” and “best I ever had”. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 18 Each person is responsible for keeping their room tidy and clean and doing as much of the routine domestic tasks as they can manage. Staff take a very active part in encouraging and assisting wherever necessary. In this way people control their own environment and what their room means to them. One person who needed a specialist seat to help getting into his bath had this fitted the day before the inspection. The kitchen was modern and fitted to a high specification. It was clean and of an ordinary domestic style that was suitable to the needs of people who are encouraged and supervised to use this facility. The home has a small grassed garden with a seating area at the rear of the property. Access to the garden is down a secure concrete ramp with grab bars each side. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 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): 32,34,35, People using the service experience good quality outcomes in this area. People are assured they are supported by satisfactorily trained staff who have been safely recruited. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a small cohort of staff of an acting manager, two senior support workers and four support workers. The acting manager and two staff informed us that agency workers are not employed. Staff were observed to be competent and demonstrated they knew people’s needs and described these to use when we spoke to two staff. They were competent is communicating with people and in listening to people views and generally focused on what people were saying. The home is supported by a behavioural specialist team employed by the organisation. The team provides advice and emergency intervention, if necessary. A behavioural specialist from this team was visiting the home on the day of the inspection and explained her role to us in the preparation of a person who is considering moving into the home. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 20 Staff training records showed they had received an initial brief induction and a longer induction in a common induction through ‘E learning’. The brief induction did not include any safeguarding element. Competencies of new staff are assessed by the acting manager in the common induction programme. This ‘E learning’ induction mirrors the Skills for Care Common Induction Standards and these were discussed with the manager as a tool for new staff who could be registered as competent with the Skills for Care Council. Staff were expected to complete this common induction within six weeks. Training is provided in Fire Safety; First Aid; Health & Safety; Food Hygiene; Infection Control; COSHH; managing Medication; Autism and Conflict management. Three staff have an LDQ level 2 award in care. Further training is being planned in Deprivation of Liberty and the Mental Capacity Act. The acting manager informed us that she was considering arranging some training in Safeguarding and the Safe Administration of Medication that is provided by the local Primary Care Trust. The home has access to the organisation’s trainers and informed us that training is also provided through their ‘in-house’ trainers and ‘E learning’ and through external trainers. Staff recruitment records were satisfactory and contained appropriate details expected by the Care Homes regulations 2001. The records were neatly maintained and easy to read and all referees had been addressed by letter. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 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): 37,39,42, People using the service experience good quality outcomes in this area. People are assured the home is safely managed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The existing manager has left the company and had not informed the Commission. The acting manager who has been in post only two weeks, said she would write and inform the Commission of this fact and would speak to the organisation’s responsible person about this. Staff working rosters are arranged so that staff have a generous amount of time away from work. This working arrangement was agreed with staff. The management of staff was demonstrated to be good. There were well planned Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 22 and open negotiations about their holidays, access to and use of the home’s internet and the company’s intranet to enable staff to develop knowledge. The acting manager’s office had details of staff meetings, rosters, holidays and topics for discussion at team meetings posted on the notice board staff were observed to have open access to the office and to the acting manager. It was observed that people’s views are listened to by staff and by the acting manager who knew the needs aspirations and the potential of the people at the home. The home has not developed a quality assurance system to reflect the views of people. The manager can report to a ‘best practice’ group within the organisation to suggest how practice and management might be improved. Safety in the home is promoted. All doors to stores of hazardous substances were locked; there was a fire risk assessment and an evacuation plan is prepared in case of an emergency, or disaster. Fire alarms had been tested weekly and fire drills had been recorded as having been carried out. Portable electrical appliances had been tested. A range of appropriate policies and procedures were seen. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 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 X 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 4 26 X 27 4 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Version 5.2 Page 24 Fletton Avenue DS0000073024.V375556.R01.S.doc N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA20 YA35 YA35 Good Practice Recommendations The periodic auditing of medication by the home should not be entered onto the MAR charts, so that there is no confusion about the entries written onto this record. The initial induction provided for new staff should include safeguarding. Staff should be registered with the Skills for Care Council if they have successfully completed the Skills for Care Common Induction Standards. Fletton Avenue DS0000073024.V375556.R01.S.doc Version 5.2 Page 25 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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