Care Home: Flint Green House

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What the care home does well The pre admission assessment process at the home was very thorough and the individuals being admitted were fully involved in drawing up the plans. They were able to visit the home on several occasions building up the amount of time they spent at the home culminating in overnight stays. The home supported individuals to maintain and develop their independent living skills so that they were able to move into more independent living. The people living in the home were well aware of what their aims were and how they were going to achieve them. There were regular reviews to ensure that people continued to develop their skills or were helped to understand what further improvements were needed. People who have moved onto independent living are able to visit the home resulting in somewhere individuals could go to for ongoing support and advice. All the people living in the home were preparing their own food. They were assisted to budget, shop and prepare their meals. They were advised on eating a healthy diet. There were good relationships evident between the staff and the people living in the home. One person spoken to during the inspection who was working towards discharge said that he was `very happy here and wanted to go independent. He was doing his own cooking, cleaning and shopping`. The people living in the home told us that they were able to talk to the staff about any concerns they had. What has improved since the last inspection? The home has introduced health action plans and these are being further developed. New furniture had been purchased for the lounges so that they were very comfortable. New wooden flooring had been laid in the communal areas on the ground floor. Heating and lighting had been fitted in the conservatory making it more comfortable for the people living in the home.DS0000072768.V374792.R01.S.docVersion 5.2 What the care home could do better: The registered person needed to ensure that the hot water delivered from the showers was not hot enough to scald people living in the home. Some fittings in the main kitchen could be replaced including some units and fridges that were starting to go rusty. Some of the bathing facilities were not homely and they would benefit from upgrading. Some cracks were noted in the corridor on the first floor. These needed to be looked into for the cause and severity. The registered person needed to ensure that the staffing levels were sufficient to meet the needs of the people living in the home. The registered person must ensure that all the staff have undertaken the training needed to ensure that they have all the skills and knowledge needed to care for the people living in the home. The training matrix should be updated to reflect this. Key inspection report CARE HOME ADULTS 18-65 Flint Green House 4 Sherbourne Road Acocks Green Birmingham West Midlands B27 6AE Lead Inspector Kulwant Ghuman Unannounced Inspection 3rd April 2009 09:00 DS0000072768.V374792.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. DS0000072768.V374792.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 DS0000072768.V374792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Flint Green House Address 4 Sherbourne Road Acocks Green Birmingham West Midlands B27 6AE 0121 708 2131 0121 707 0209 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) Midland Heart Limited Manager post vacant Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places DS0000072768.V374792.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: Either Whose primary care needs on admission to the home are within the following categories: Mental Disorder (MD) 15 The maximum number of service users to be accommodated is 15 2. Date of last inspection New Registration Brief Description of the Service: Flint Green is a large two storey building situated in private grounds set back from Sherbourne Road in Acocks Green. The home is within walking distance of bus and rail routes, and is within close proximity of Acocks Green shops and facilities including parks, restaurants, places of worship, library and a sports centre. The buildings and grounds have distinctive character and blend in well with surrounding properties. All the people living in the home have individual bedrooms; there are two lounges both of which are non smoking, two kitchens and a laundry. Toilet and bathing facilities are communal. A garage and an outbuilding are used for leisure purposes; housing a pool table, snooker table and a gym. Access in and around the home would be difficult for anyone with mobility issues. The home provides rehabilitation services as opposed to long stay placements for fifteen younger adults with mental health needs. Places at the home provided are for time limited rehabilitation, and users of the service are expected to move on within eighteen months of being placed at the home. The services at Flint Green are based on recovery models that emphasise the individual managing his or her own life as opposed to just being treated for an illness. The service user guide for the home explained the funding arrangements for staying at the home which are typically paid by Social Care and Health and DS0000072768.V374792.R01.S.doc Version 5.2 Page 5 were £568.00 per week at the time of the inspection. The service user guide also indicated that in some circumstances individuals may be required to pay a personal contribution. If this were the case it would be explained by the social worker involved in the admission. DS0000072768.V374792.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out over one day. The home did not know we were going to visit. The focus of inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, standards of practice and focuses on aspects of service provision that need further development. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the last key inspection. This included notifications received from the home. These are reports about things that have happened in the home that they have to let us know about by law, and an Annual Quality Assurance Assessment (AQAA). This is a document that provides information about the home and how they think that it meets the needs of people living there. Two people living in the home were case tracked. This involves establishing individual’s experiences of living in the care home by meeting them, observing the care they receive, discussing their care with staff, looking at care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. We looked around some areas of the home. A sample of care, staff and medication records were looked at. Where people who use the service were able to comment on the care they receive their views have been included in this report. We received 6 surveys completed by people who use the service and 4 people who worked there. We had not received any complaints about the service since the last key inspection. DS0000072768.V374792.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? The home has introduced health action plans and these are being further developed. New furniture had been purchased for the lounges so that they were very comfortable. New wooden flooring had been laid in the communal areas on the ground floor. Heating and lighting had been fitted in the conservatory making it more comfortable for the people living in the home. DS0000072768.V374792.R01.S.doc Version 5.2 Page 8 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. DS0000072768.V374792.R01.S.doc Version 5.2 Page 9 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 DS0000072768.V374792.R01.S.doc Version 5.2 Page 10 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, 4 and 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People moving into the home are given the time and support to ensure that the home meets their needs and expectations. EVIDENCE: The statement of purpose was not examined at this inspection as it had been seen by the registration team when the provider for the home, Midland Heart Ltd, were registered as the provider in October 2008. As part of this inspection we followed the admission process for one person who had moved into the home since the last inspection. It was found that there is a comprehensive admission process that involves the individuals visiting the home on several occasions to build up the amount of time spent in the home leading to overnight stays. The individual told us in a completed survey, Came to see it and I liked it. I asked a lot of questions and got a lot of answers. DS0000072768.V374792.R01.S.doc Version 5.2 Page 11 A risk and needs assessment is completed which covers areas such as mental health, social inclusion, recreation and life skills. Meetings with the individuals and other professionals involved in their care were held to agree the visiting programme to the home so that everyone was aware of the expectations. The admission process for the person whose care was being tracked lasted nearly four months. Records showed that people are introduced to the other people living in the home, given keys to the home and their bedrooms and informed of basic rules in the home such as respecting other peoples space, knocking on doors before entering bedrooms, responding to fire alarms and no threatening behaviours. Part of the admission process included issuing the individuals with a licence agreement to ensure that they knew what services they could expect from the home. DS0000072768.V374792.R01.S.doc Version 5.2 Page 12 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 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home were involved in setting objectives and planning how these would be achieved and how their personal risks would be managed. EVIDENCE: The files for two people living in the home were looked at. Both of the files showed that there were needs and risk assessments in place. Both of the individuals had been involved in drawing up their goals, how they were going to be reached and the risk management plans that had been put in place. The people whose care was being tracked were independent in most tasks but needed to be supported to achieve their goals. DS0000072768.V374792.R01.S.doc Version 5.2 Page 13 The AQAA told us that the Risk and needs documentation is started at assessment stage and continues throughout their stay. Support plans are discussed and reflect needs and take into account choices. Progress reviews are held and documented. Key and co work sessions are held where there are opportunities to discuss choices, needs and wishes. The documentation that we looked at confirmed this. Key worker sessions were held regularly with the individuals and issues such as personal safety, insight into their illness and their future plans were discussed. There were agreements in place to ensure that the individuals knew what the expectations from them were. Some of these were specific to the individual for example, the time they had to be back in the home, and some were general rules for living in a communal setting such as respecting other people’s personal space. There were extensive risk assessments in place. These included issues such as their mental relapse indicators and risks due to individual lifestyles. For example, for one individual they had agreed the time they needed to come back to the home at night and that they needed to let staff know where they were going and what time they planned to return during the day. It was quite clear the individuals knew what actions would be taken if they did not return and that there was a management plan for this in place. Individuals were encouraged and supported to develop their daily living skills such as budgeting, shopping, cooking and cleaning. This was important as the overall aim of the home was for individuals to live independently. One person spoken to during the inspection who was working towards discharge said that he was very happy here and wanted to go independent. He was doing his own cooking, cleaning and shopping. The home had obviously been quite successful in this aim as during the day of the inspection there were a number of people who had come back to visit after they had moved into individual accommodation. It was pleasing to see that the individuals felt comfortable to come back and ask for advice on such as gaining a place on an apprenticeship scheme. The individuals were consulted on what they wanted to do. For one individual they had indicated that they wanted to attend college and be assessed for dyslexia as they felt this was holding them back. The staff were in the process of helping them achieve this. DS0000072768.V374792.R01.S.doc Version 5.2 Page 14 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, 13,14, 15 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home were supported to develop their skills and maintain contact with friends and family to ensure that they were equipped to move to more independent living. EVIDENCE: The homes main aim is one of helping the people living in the home to become independent and skilled in daily living activities to enable them to move to independent or supported accommodation if possible. The home was clearly achieving this as some people had moved out of the home since the last inspection and some were coming to the end of this process. DS0000072768.V374792.R01.S.doc Version 5.2 Page 15 The two files looked at showed that there were plans in place for the individuals to achieve this goal. For one person they were coming to the end of this process but the other one was still in the early stages. The files showed that there were individual activities planned for most days. Some of these were in the home and some were outside. These included developing cooking skills and attending Caribbean days and so on organised by the home. People also attended colleges and some voluntary work placements. There was evidence of contact with families and friends in the local community. As stated earlier there was contact with people who had moved to more independent accommodation and this was a good incentive for the people living in the home. During the day staff were observed taking someone to see accommodation that they could be potentially moving in to. There were leisure facilities in the home for people including table tennis, snooker, pool, darts, football table, push bikes and gym equipment. People could just relax watching the television in the lounges or in their bedrooms as well as using the computer in the resource room to develop their computing skills or driving skills or just playing games. Surveys completed by the people living in the home indicated that they were happy with the services provided in the home. One person said they could do most things they want. Another said We are looking forward to going on holiday. The home had developed a womens group that discussed issues such as mental health, personal safety and healthy eating. A mens group was also going to be set up. There were other groups in place such as the art group that people could get involved in. All the people living in the home cooked for themselves. They were given support with budgeting, shopping and preparing meals. People could buy what they liked to eat and one person told us that he cooked some Caribbean meals that he had been taught by his mum. The staff tried to encourage people to eat healthy meals. There was a kitchen that was used by people who were preparing to move to independent accommodation. They had keys to the kitchen so that they could access it unsupervised at any time. The other kitchen was used for training purposes. DS0000072768.V374792.R01.S.doc Version 5.2 Page 16 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 and 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home were supported to access medical services as needed and supported to develop their skills in managing medicines. EVIDENCE: The people living in the home are mainly independent in terms of personal care. People generally needed only prompting and reminding to carry out these tasks. The people seen during the inspection were all dressed in individual styles that reflected their personalities and cultures. The AQAA told us that they had introduced health action plans and they planned to ensure that in the next 12 months everyone had a health care plan in place. DS0000072768.V374792.R01.S.doc Version 5.2 Page 17 There was evidence in the files sampled of regular contact with workers from the mental health teams. There were regular reviews and relapse indicators for mental health illnesses were recorded. Medication reviews were regularly carried out and people living in the home are getting assistance on healthy lifestyles that includes diet and exercise. Surveys completed by staff in the home told us that they supported people living in the home at appointments and with medication management. The records sampled during the inspection showed that individuals were supported with their emotional needs such as relationships with children and partners. The people living in the home were at various stages of managing their medicines. Some people came to the office to get their medication, others had their medicines on a daily or weekly basis or were totally responsible for their medication. Compliance checks were in place to ensure that medicines were being taken appropriately. People signed for the medicines they received. People were supported to have blood tests undertaken as needed. The medication records for two people were checked and found to be in order. There were no controlled medicines in use at the time of the inspection. Temperatures for the medication fridge were recorded. Medicines had been booked in appropriately and they could all be audited showing that people were receiving their medicines as needed. DS0000072768.V374792.R01.S.doc Version 5.2 Page 18 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 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home are safeguarded and know who they can turn to if they have any concerns. EVIDENCE: As at the last inspection the complaints procedure was available on the notice board in the home and in the service user guide. No complaints had been lodged with us and none had been made directly to the home since the last inspection. Completed surveys returned to us indicated that people generally knew who to speak to if they had any concerns. One person said Will speak to Roz, my manager and staff. Staff sometimes dont talk to me when I want to. Sometimes they do but sometimes not. There had been no adult protection issues raised since the last inspection. There was information available regarding safeguarding of vulnerable people and this issue was discussed with the people living in the home during a womens group discussion. DS0000072768.V374792.R01.S.doc Version 5.2 Page 19 Information sent to us by the manager about people not returning to the home at the agreed times show that issues have been handled appropriately and the people living in the home have been protected. DS0000072768.V374792.R01.S.doc Version 5.2 Page 20 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 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises were comfortable, homely and clean and met the needs of the people living in the home. EVIDENCE: A tour of the communal areas of the home was undertaken. The premises had not changed in structure since the last inspection. There were two lounges and dining rooms, a resource room and an annexe that was used for leisure activities. The annexe, a converted garage, housed games equipment such as snooker and football tables, cycles to be used by the people living in the home and fitness equipment. There were facilities for people to make drinks and stereo DS0000072768.V374792.R01.S.doc Version 5.2 Page 21 system so that they could listen to music. The annexe was being used during the inspection. The conservatory had had heating and lighting fitted and there was a table tennis table in there. The conservatory could do with being repainted. The furniture in the main lounge had been replaced and it looked very comfortable and contemporary in style. The carpet had been replaced with wooden floor in the lounge and passage ways. People who had lived in the home previously and who had come back to visit during the inspection commented on how nice the wood flooring looked. The dining room was comfortable. The kitchen was clean and suitable for its purpose. Fridge and freezer temperatures were being recorded ensuring that food was being stored safely. The kitchen was becoming dated, some drawer fronts had expanded due to water damage which made it difficult to maintain good infection control and the fridge was starting to rust. We did not see any of the bedrooms on this occasion however they have been seen previously. There were several bathrooms, toilets and showers throughout the home. Some of them were quite basic and would be improved by some refurbishment. Hot water from one of the showers was found to be too hot and the temperature needed to be restricted to ensure that no one was at risk of scalding. There was water damage and cracks in the corridor on the first floor of the home. These issues needed to be addressed to ensure the structure of the home was safe and the home remained homely and comfortable for the people living there. The laundry room housed two washing machines and dryers and people living in the home were able to access it to carry out their own laundry. The resource room housed a computer that was used by the people living in the home. The people living in the home told us that they were happy with the accommodation. DS0000072768.V374792.R01.S.doc Version 5.2 Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels in the home needed to ensure that the needs of the people living in the home could be met at all times. Some staff needed to have specific training to equip them with the knowledge and skills to meet the needs of the people living in the home. EVIDENCE: The staff rota was provided and it showed that during the day there were usually 4 or 5 staff on duty and two during the evening with two sleeping in staff at night. At weekends there were two staff on duty throughout the day. There were domestic staff available to clean the communal areas of the home. The staffing levels were discussed with the manager who stated that the home was fully staffed. The manager felt that the current staffing levels met the needs of the people living in the home as they tended to be occupied during the day and staff were available to support them but in the evenings they DS0000072768.V374792.R01.S.doc Version 5.2 Page 23 tended to stay in the home and watch television, play some games as well as cooking their meals. Three surveys commented on the staffing levels: Due to sickness sometimes we dont always have enough staff and not being able to use to many agency staff because of the cost makes it hard on full time staff ie carry out the full service. Sometimes we can be a bit short of staff and not have enough staff to support individual needs. Evenings and weekends we have a skeleton staff, ie 2 staff on duty who both have to remain on site. This can be restrictive at times ie health appointments, where resident needs support cannot take place after 4pm and likewise with leisure activities evening/weekends, unless there is adjustments to the rota. Not a major issue. She agreed to consider having an additional person available during the light evenings if this was needed. The staff had generally worked at the home for a considerable amount of time which was good for the continuity of support for the people living in the home. No new staff had been appointed since the last inspection therefore the recruitment process was not looked at during this inspection. The staff clearly saw the views of the people living in the home as being very important and that their role was to support them achieve their goals. Since the last inspection some people had had deprivation of liberty, health and safety and fire awareness training. Not all the staff had had training specific to mental health. It was important that those staff who had not received this information were provided it. DS0000072768.V374792.R01.S.doc Version 5.2 Page 24 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 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management team ensured the smooth running of the home in a competent manner. The home was well maintained and safe for the staff and. EVIDENCE: As identified at the last inspection there was no registered manager in post. Following this inspection we were notified that a new manager was to be appointed and that the current acting manager would remain in post until that time. DS0000072768.V374792.R01.S.doc Version 5.2 Page 25 It is a credit to the staff team that the home has been continuing to function well in the absence of a registered manager but it is important that the people living in the home can be assured that a registered manager is in charge of the home on a day to day basis. There was a system in place for monitoring the quality of the service offered to the people living in the home. An annual service review was being carried out by the organisation and surveys were being sent out to people and an action plan would be discussed with the people living in the home. There were regular meetings with the people living in the home that discussed issues such as activities, things they wanted to buy for the home, repairs to the home and visitors to the home. There were regular fire checks in the home and the people living in the home were expected to respond to fire alarms. Maintenance of equipment was ongoing and the AQAA indicated that this was all up to date. The only health and safety issue raised during this inspection was that the hot water temperature from the showers needed to be adjusted to ensure that the people living in the home were not at risk of scalding. DS0000072768.V374792.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 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 2 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 x DS0000072768.V374792.R01.S.doc Version 5.2 Page 27 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 YA24 Regulation 23(2) Timescale for action The issues identified in respect of 03/06/09 the fabric of the building must be attended to. This will ensure that the building is safe and well maintained. The people living in the home 14/05/09 should be protected from the risk of scalding in bathing facilities. Requirement 2 YA27 13(4)(c) 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 4 5 Refer to Standard YA27 YA30 YA30 YA33 YA35 Good Practice Recommendations Bathing facilities could be refurbished to make them more homely. The kitchen could be refurbished to make it easier to maintain good cleanliness. The fridge could be replaced as it is starting to rust and therefore could be difficult to keep clean. Staffing levels should be re-assessed to ensure they meet the needs of the people living in the home. The registered person should ensure that all the staff have had training to equip them to carry out their roles. This will ensure that the actions taken by staff are based on DS0000072768.V374792.R01.S.doc Version 5.2 Page 28 6 YA37 recent good practices. An application to register a suitable individual as the registered manager should be forwarded to the Commission. This will ensure that there is an accountable person in day to day control of the home. DS0000072768.V374792.R01.S.doc Version 5.2 Page 29 Care Quality Commission West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT 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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