Care Home: Hamelin

What the care home does well People have enough information about the home to make a decision about living there. Their needs are thoroughly assessed before they move in so that the home can be sure it can meet them. Detailed plans are made with people so that staff know what support they need and how to provide that support. The plans include information about peoples` health and people are well supported to stay healthy. There is excellent support for people to engage in activities they chose and develop their skills and interests. People are well supported to keep in touch with the wider community and people important to them. Staff are empathetic, patient and understanding. They have a good understanding of peoples` individual needs. They take peoples` concerns seriously and know how to protect them from abuse. The home has a well qualified manager who generally runs the home well and for the benefit of people living there. What has improved since the last inspection? Regular visits are made to the home by senior staff to assess the service as required by regulation. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Some practices concerning the use of medication in the home have improved. The views of people living in the home are included in the home`s quality assurance system. What the care home could do better: There have been a number of medication errors. Although these have been dealt with appropriately they should be reviewed to see if practice can be improved. The home needs to be maintained in a state of reasonable decoration and carpeting should be cleaned and/or renewed when necessary. Key inspection report CARE HOME ADULTS 18-65 Hamelin Farewell Road Totnes Devon TQ9 5LJ Lead Inspector Graham Thomas Key Unannounced Inspection 14th August 2009 09:00 Hamelin DS0000003714.V377067.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. Hamelin DS0000003714.V377067.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 Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hamelin Address Farewell Road Totnes Devon TQ9 5LJ 01803 868971 01803 868396 enquiries@comae.org.uk 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) Mr Simeon James Antony George Ramsden The Very Rev Mitred Archpriest Benedict Ramsden, Mrs Lilah Ramsden Miss Shelley Barreto-Pereira Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 2007 Brief Description of the Service: Hamelin is registered to provide care and support for up to six people with mental health needs. The home is located in a residential area close to the town of Totnes where all public amenities are to be found. This is one of a number of homes in the South Hams and Plymouth areas owned by the Community of St. Anthony and Elias which, for ease of reference, will be referred to as the Community throughout this report. People living at Hamelin are provided with a well developed activities programme including arts, crafts and outdoor activities. This is staffed by skilled specialists. Support is provided to access ordinary community facilities and engage in personal development through work and education. At the time of this inspection an application had been submitted to increase by one the number of people for which the home was registered to provide care. The current fees range from £1600 to £2100 per week. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. Before our visit, we reviewed information we had received about the home since our last inspection. This included, for example, details of any complaints received and the “Annual Quality Assurance Assessment” (AQAA) completed and returned to us by the Registered Manager. We visited the home and spent about six hours there. At the beginning of our visit we attended a staff handover meeting. During the day we looked around the home and spoke with staff and people living at the home. We “case tracked” three people. This means that we looked in detail at their records, spoke with them if possible and checked that they were receiving the care and support that was planned for them. We also looked at records concerning staff and the management of the home. What the service does well: What has improved since the last inspection? Regular visits are made to the home by senior staff to assess the service as required by regulation. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 6 Some practices concerning the use of medication in the home have improved. The views of people living in the home are included in the home’s quality assurance system. 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. Hamelin DS0000003714.V377067.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 Hamelin DS0000003714.V377067.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): Standards 2 and 4 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. Before people move into Hamelin, a thorough assessment is made so that the home knows it can meet their needs. The person has good opportunities to visit the home and find out what it is like to stay there. EVIDENCE: In the Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager, she told us that: “Services users are well informed about the Community. They are encouraged to meet other service users and staff and have overnight visits before they make a decision on their placement. New service users are admitted after a full assessment of their needs has been undertaken. Service users new to the house have a say if they are happy with the placement. They also strongly encouraged to have an overnight visit prior to their placement and freedom to choose their placement.” We spoke with a person who had recently moved in. They said that they had received enough information about the home before moving in and had the Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 9 opportunity to visit and spend a night at the home beforehand. We looked at their records. A very thorough assessment of the person’s needs was recorded in their file. This included information received from the person’s previous hospital placement, their care plan and a meeting with their social worker. The person was seen in hospital by the Community’s own Consultant Psychiatrist. Visits to the home by the person were then arranged which included an overnight stay. The outcome of this assessment was then summarised and placed on file. A care plan had then been produced based upon the assessment. Hamelin DS0000003714.V377067.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): Standards 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. People living at Hamelin can feel confident that their needs are well understood and that they will receive good support to make decisions about their lives. EVIDENCE: We looked at three people’s individual files. These contained individual care plans and supporting information. There were also files of daily notes concerning each person. The plans were detailed and covered areas such as personal support, medicines and alcohol, mental health and risk management plans, contact with family and friends and activities outside the home. The daily notes were detailed and were very clearly linked to the individual objectives of each care plan. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 11 We spoke to one person who told us about the support they received and we checked that this matched what was described in their plan. The person’s care plan and daily notes described how they would be supported, for example, to maintain contact with family members and attend medical appointments. The person described staff as “very supportive”. They confirmed that they had been helped to maintain contact with family members and to attend appointments with their GP. At the staff handover meeting we heard how this support was being managed. The person visited the GP on the day of our visit with staff support. Another person’s plan described the support they were receiving to attend college. We saw a risk assessment about this and notes describing the support the person had received. Displayed on the wall in the home were certificates from the courses the person had completed successfully. We spoke with the person who told us about the courses they were to attend in the new academic year and saw notes in the files confirming arrangements for this. A third person’s interest in gaming with miniature figures was described in their plan. On the day of our visit the person told us that they were going out to meet friends and pursue this interest. In each instance, the activities being followed by individuals had been risk assessed. The level of support each person received was clearly related to the level of independence that the person had achieved and assessments of their mental health. The plans and risk assessments had been regularly updated and amended to reflect changes and fluctuations in the level of support they required. The goals in each person’s plan, agreed with them where possible, reflected movement towards as much independence as possible for the individual. Our attendance at the staff handover meeting confirmed that staff had a detailed awareness of each persons needs and personal goals. Hamelin DS0000003714.V377067.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: Standards 12, 13, 15, 16, and 17 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Hamelin receive excellent support to pursue their chosen lifestyle and develop their abilities and interests. EVIDENCE: In the Annual Quality assurance Assessment returned to us, the manager stated that , “One ..(person).. attended a years pottery course at the Mansions adult education centre in Totnes. This has given (the person) the confidence to apply for a course in ceramics at South Devon College. (Another person)… has undertaken a years course at the Mansions studying English and Maths; this finished with an exam. Another ..(person).. took a four day aromatherapy course; this has given (the person) the confidence to explore new activities. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 13 Also another ..(person).. went on a weeks holiday to Butlins, which (the person) thoroughly enjoyed. (The person) has also been on a few taster days at Brixham College doing pottery and textile classes. (The person) will be starting a one-day course in September which also has social events. Last September I took a group of residents to Sicily. They all had a fantastic time and I have asked about the possibility of another trip.” Our examination of individual files and discussion with people living at Hamelin confirmed these activities. We also saw displayed on a wall certificates relating to the English and Maths courses attended by one person. In addition, one person told us how they were being supported to undertake voluntary work in a local shop. We found that each person had an individual activities plan which included activities run and supported by the Community. For example, these included cycling, camping, 5-a-side football, music art and cooking. A monthly newsletter was also seen with notes and photographs of the Community’s outdoor activities programme. During our visit we noted that individual routines were flexible to accommodate these individual plans. Up to date risk assessments were in place in individual plans covering activities such as college attendance and outdoor activities. We spoke with one person who confirmed the arrangements described in their plan for maintaining contact with their children. These arrangements had been agreed and co-ordinated with the various involved agencies and professionals. Another person told us about meeting with friend to pursue an interest in games with miniature figures. We saw that each person’s bedroom was fitted with a locking device and confirmed with individuals that they had been offered a key. During our visit we saw that staff were respectful of each individual’s personal space such as their bedrooms. They demonstrated this by knocking before entering and asking permission to enter. We joined people living in the home and staff for a lunchtime meal. People were supported and encouraged to help with preparation and clearing away. Meals are planned daily and people living in the home are involved in shopping for the necessary groceries and other items. The meal was an informal occasion where all those attended chatted amiably. Individual preferences were catered for and people discussed other meals they had eaten and / or prepared. One person was being supported and encouraged by staff to follow a diet recommended to promote their good health. Another person did not wish to join the group and was able to exercise this choice. Records are maintained of the meals taken and these reflected a balance between individual choice and a healthy, varied diet. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 14 Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 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. People living at Hamelin can feel confident that their personal support and healthcare needs will be well met. EVIDENCE: During our visit we saw that people’s appearance and dress reflected their individual tastes and choices. Each person’s routine reflected the individual programmes identified in their care and activity plans. In one instance we heard staff sensitively encouraging one person to begin their morning routine so that they could pursue a chosen activity. We heard staff offering prompts and encouragement to one person to follow a diet recommended to maintain their good health. Staff had also left fruit in the person’s room further to encourage healthy eating habits. Our inspection of individual plans and discussion with staff and people living in the home confirmed that the physical and psychological health of people living there were being effectively monitored. At the staff handover, staff spoke knowledgeably about the monitoring and management of one person’s Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 16 diabetes. This was reflected in the person’s individual plan which contained monitoring records, details of treatment by a podiatrist and how the person was being supported to maintain a diet compatible with their condition. Support was given by staff during our visit for one person to attend an appointment with their GP. The person told us that they welcomed the support of staff to attend the appointment. Another person had recently been admitted to hospital. Staff described their regular visits to the person pending their return to the home. We also heard how staff had noticed that a person required treatment to their eyes and how this had been addressed by the use of a prescribed cream. The Community has its own consultant Psychiatrist who provides guidance advice and mental health monitoring We looked at how medicines are managed in the home. Medicines are stored in a secure cupboard in which there is further locked storage. Additional security is provided for controlled drugs whose use was recorded in a separate controlled drugs register. A list of homely remedies, approved for use in the home by a GP was seen in the medication cupboard. Some people had been prescribed “as required” medication. In all but one instance there were written protocols for staff about the use of this medication. This protocol was being written up at the time of our visit and staff understood the use of the medicine. Records concerning medication were generally in order. However, we noted that a significant number of medication errors had occurred recently. In each instance, we had been notified as required by regulation and staff and management had taken appropriate action. However, we recommend that a review of these errors should be conducted to identify any patterns and potential improvements to the home’s medication systems. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 living in the home can feel confident that their concerns and complaints will be treated seriously and acted upon. There are sufficiently robust systems in place to safeguard people from abuse. EVIDENCE: We looked at how the home deals with peoples concerns and complaints and how people are protected from abuse. The home has policies concerning complaints, safeguarding people from abuse and whistle-blowing. The complaints procedure is provided to people living in the home. People with whom we spoke in the home felt that staff would treat any concerns seriously and act upon them. The Registered Manager told us in the Annual Quality Assurance Assessments that, “Most concerns are handled within the context of the ordinary daily life of the house. These would be documented within the residents daily record books/other house records. There is a residents complaints file held in the managers office for any formal complaints made.” Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 18 Our examination of the home’s records and individual care plan files confirmed this. We also checked our own files and found that no complaints had been made about the service since our last inspection. Staff files showed that they had received training in safeguarding vulnerable adults from abuse. When we spoke with staff they were able to identify what might be considered to be abuse and how they would respond to any that might be alleged, suspected or witnessed. Behaviour which might challenge the service was recorded in the individual care plan files and, where necessary, risk assessed. We also saw that in relation to the management of one person’s needs, a best interests assessment had been made in accordance with the Mental Capacity Act and Deprivation of Liberty Safeguards. During our inspection of the home’s records we confirmed information provided by the service that the home had intervened to prevent one person running up debt. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Hamelin provides a sufficiently homely environment though the standard of décor has deteriorated since our last inspection. Hygiene and the control of infection were generally satisfactory though a minor improvement is recommended. EVIDENCE: We looked at the safety and homeliness of the premises. Hamelin is in a quiet residential area within walking distance from the nearby town of Totnes. The building has been extended and substantially modified over a period of years. The accommodation is on three levels. The front entrance is on the lower ground floor where there is a large laundry room. Stairs lead to the next floor which is level with the rear garden. On this level there are five individual bedrooms, a shower room, a lounge, activities room, kitchen, dining area and office accommodation. At the next level there is a further bedroom and two bathrooms. Staff sleeping in accommodation is provided on the third level. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 20 At the time of this inspection visit an application was in progress to increase the maximum number of people who may be accommodated at the home. The former large laundry space had been divided and part of this was being converted to a bedroom with en-suite facilities. Maintenance records were available for inspection. These recorded routine and one-off maintenance. For example, there were records of a gas safety check, a satisfactory fire safety audit, repairs to the shower, and the testing of portable electrical appliances. We also saw environmental risk assessments. Our tour of the home showed that the environment provided homely, domestic style accommodation. Bedrooms were personalised with personal possessions, pictures and individual décor. Communal areas also contained items important to people living in the home. However, in several areas the décor was shabby and the carpeting stained and/or worn. One person with whom we spoke made unsolicited comments to us that this was unsatisfactory. We examined the steps taken to maintain good standards of hygiene and to control infection. As previously described, the laundry facilities in the home had been divided to provide an additional bedroom. This had reduced the available space and made it more difficult to divide clean and soiled laundry. The laundry facilities comprise two washers and a dryer. Staff told us that the washing machine had appropriate hot wash cycles. Soluble red bags were in use for potentially infected laundry. A sink for hand washing was available in the laundry. Paper towels were available for staff use but there was no soap at the sink. We saw that aprons and gloves were available for staff use to prevent the spread of infection. Outside the home we saw yellow bins for the disposal of hazardous waste. We also noted in our tour of the premises that all hazardous cleaning materials had been locked away when not in use. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 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 are well supported by the staff team trained to meet their needs. EVIDENCE: One person living in the home told us that “The staff here are really great. I get really good support”. We observed staff at work, attended a staff handover meeting and held individual discussions with staff members. This revealed that staff were respectful, patient, empathetic and had a good understanding of people’s individual needs. At the time of our visit there appeared to be enough staff to support people to pursue individual routines and meet their individual needs. However, we did note that the home had been through a period in which some people’s individual needs and the challenges they presented had increased. On the day of our visit, one person had not had a break for many hours and appeared tired. Levels of support required at night had increased. The home does not routinely have waking staff at night thought the service’s Personnel Manager Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 22 told us that after a disturbed night, provision was available for people to sleep in the day. We looked at how the home recruits staff. We examined two files of staff who had recently been recruited. We saw in each file that a safe recruitment procedure was in operation. This included a formal application process in which written references were required and obtained. Similarly, a full employment history had been obtained as well as a statement concerning the medical fitness of the person to undertake the work. Criminal record checks had been obtained before the person commenced duties. This process was confirmed by staff with whom we spoke individually. Staff had individual training files containing evidence of training including training notes and certificates. These showed that new staff were provided with detailed induction training which included, for example, training about mental health needs and health and safety topics. Evidence of training in subjects relevant to people’s roles was seen in individual staff records. This included, for example, the administration of medicines and safeguarding vulnerable adults from abuse. The Community of St. Anthony and St Elias has rolling programme of training for National Vocational Qualifications in care. One staff member we interviewed told us about her impending enrolment for such a course. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Hamelin is generally well run by a manager committed to meeting the needs of people living there. EVIDENCE: Shelley Barreto-Pereira, the Manager of Hamelin, was Registered with the Commission in April 2006. She has completed a National Vocational Qualification (NVQ) in care at level 4 and the Registered Managers Award. She has also qualified as an NVQ assessor and is about to embark on studies at degree level in psychology and criminology. Within the Community, she is involved in delivering in-house infection control, food hygiene and manual handling training and regularly attends infection control forums and training sessions run by Devon Primary Care Trust. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 24 At the time of our visit she was taking a day’s annual leave. The management of the home had been delegated to another senior member of staff. A system was in place to monitor the quality of the service provided. This includes feedback from people using the service. Other auditing systems provide the basis for continuing improvement. For example, incidents in the home are fed back to and monitored by senior staff. We saw examples of how practices had been modified in response to reported incidents. We also saw evidence of regular visits by the Responsible Individual as required by regulation. We looked at the management of health and safety issues. Staff files showed evidence of training in health and safety topics such as moving and handling and infection control. Maintenance records showed that safety checks such as those for gas safety and portable electrical equipment had recently been completed. Risk assessments both for individual and environmental risks were in place. The local fire and rescue service had recently conducted a fire safety audit in the home. Though not comprehensive, the audit concluded that satisfactory standards were in operation. Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 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 4 12 4 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X X 3 Version 5.2 Page 26 Hamelin DS0000003714.V377067.R01.S.doc 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. Refer to Standard YA20 Good Practice Recommendations The Registered person should conduct a review of medication errors to establish whether there are any identifiable patterns of poor practice and / or areas for potential improvement. The Registered Person should ensure that all areas of the home are maintained in a state of reasonable decoration and that carpeting is cleaned and/or renewed when necessary The Registered Person should ensure that the laundry arrangements allow for a clear division between clean and dirty laundry The Registered Person should ensure that liquid soap is available for staff use in the laundry 2. YA24 3. 4. YA30 YA30 Hamelin DS0000003714.V377067.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission 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. Copyright © (2009) Care Quality Commission (CQC). 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