Care Home: Kirkley

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What the care home does well The home is a well maintained, purpose built care setting that provides a clean and homely environment for service users during their planned periods of intermediate care. The design and layout of the home is geared towards prompting service user`s independence. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 The returned comment cards from service users indicated that they received the care and support needed. One comment was `nothing is too much to ask, `staff are excellent`. One service user spoken to during the visit said `the care and especially the physiotherapy has been great, it has been well worth coming`. One staff comment was that the home gives `good support for rehabilitation and independence` and another staff comment was when asked what the home does well was `the care service is really good`. The PCT staff and the staff employed by Inspirit care work well together as an intermediate care team that have a multidisciplinary approach to the rehabilitation of service users. This means that the service users receive a service that promotes faster recovery from illness and maximises independent living. Before service users are admitted to the home they have a full assessment of their needs to make sure that the home can meet those needs. Information received in the majority of comment cards indicated that there were always activities arranged within the home and there was a daily programme of activities on the back of everybody`s bedroom doors. Some of the activities were therapeutic for example the anxiety management or exercise sessions and some were social for example bingo or films. People spoken to were all complementary about the food provided and the received comment cards indicated that service users liked the food. One staff comment was that the home `provides good nutritious meals for the service users` What has improved since the last inspection? This was the first inspection since the service has been registered with the providers Inspirit Care Limited. What the care home could do better: No requirements were made during this visit.KirkleyDS0000072943.V375014.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Kirkley 2 Albert Grove Longsight Manchester M12 4WB Lead Inspector Geraldine Blow Unannounced Inspection 18th May 2009 09:00 DS0000072943.V375014.R01.S.do c 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 homes for older people 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. Kirkley DS0000072943.V375014.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 Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkley Address 2 Albert Grove Longsight Manchester M12 4WB 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) 0161 224 2295 0161 248 7156 Inspirit Care Limited Teresa Martina Caldwell Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Kirkley DS0000072943.V375014.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 Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 30 Date of last inspection N/A Brief Description of the Service: Kirkley used to operate under the name of Manchester care. It was part of a larger organisation that provided care and support services across the North West region. In November 2008, this organisation merged with ‘Community Integrated Care’, a national care provider, and became ‘Inspirit Care limited’, a ‘not for profit’ voluntary organisation and a registered charity. The home is registered to provide accommodation for a maximum of 30 places for people who require intermediate care services. Inspirit Care Limited in partnership with Manchester Children, Families and Social Care Services (MCFSCS) and the Central Manchester Primary Care Trust (PCT) provide the intermediate care service at the home. Bedroom accommodation is provided on the ground and first floors. Access to the first floor is via a passenger lift and stairwells. None of the bedrooms have en-suite facilities but do have hand-washing facilities. Accessible toilets and bathrooms are located on the ground and first floors within close proximity to bedrooms and lounges. The home has gardens to the front lawns, planted areas and mature trees. At the rear of the building there is a garden with a seating area for people to sit Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 5 when the weather is fine. A car park is located at the side of the building, which boarders a lunch club situated in the same grounds. Kirkley is situated in the Longsight area of Manchester close to public transport links into Manchester City Centre and Stockport town centre. The home has a no smoking policy. Kirkley DS0000072943.V375014.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 3 star. This means the people who use this service experience excellent quality outcomes. This report is the first inspection report since Inspirit Care Limited was registered with the Care Quality Commission (CQC) in November 2008. This report is based on information gathered by the CQC during the unannounced visit on the 18 May 2009 and supporting information received in Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. The visit took place on Monday 18 May 2009. This report is an overview of what the inspector found during the visit. References to we or us in this report represent the CQC. Staff and some people receiving a care service at the home were sent comments cards so that we could get their views on how the home is run. We were told that people receiving a care service at Kirkley are called service users and therefore that is what they are referred to in this report. We received six completed comment cards from staff and five comment cards from service users. Some of the comments are included in the body of the report. As part of the visit we spent time examining relevant documents and files. We also spent time talking with service users and some members of staff. We also walked round the home and looked at the communal areas and some bedrooms. Feedback was given to the senior carer who assisted us during the course of the visit. What the service does well: The home is a well maintained, purpose built care setting that provides a clean and homely environment for service users during their planned periods of intermediate care. The design and layout of the home is geared towards prompting service user’s independence. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 7 The returned comment cards from service users indicated that they received the care and support needed. One comment was ‘nothing is too much to ask, ‘staff are excellent’. One service user spoken to during the visit said ‘the care and especially the physiotherapy has been great, it has been well worth coming’. One staff comment was that the home gives ‘good support for rehabilitation and independence’ and another staff comment was when asked what the home does well was ‘the care service is really good’. The PCT staff and the staff employed by Inspirit care work well together as an intermediate care team that have a multidisciplinary approach to the rehabilitation of service users. This means that the service users receive a service that promotes faster recovery from illness and maximises independent living. Before service users are admitted to the home they have a full assessment of their needs to make sure that the home can meet those needs. Information received in the majority of comment cards indicated that there were always activities arranged within the home and there was a daily programme of activities on the back of everybody’s bedroom doors. Some of the activities were therapeutic for example the anxiety management or exercise sessions and some were social for example bingo or films. People spoken to were all complementary about the food provided and the received comment cards indicated that service users liked the food. One staff comment was that the home ‘provides good nutritious meals for the service users’ What has improved since the last inspection? What they could do better: No requirements were made during this visit. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 8 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. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 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): 3&6 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. Service user’s needs are assessed before admission to ensure their needs can be met. EVIDENCE: Service users are admitted for a planned period of assessment and rehabilitation, usually for a period of up to six weeks. Before admission to Kirkley a detailed assessment of needs is undertaken initially by an assessor based at Manchester Royal infirmary (MRI). Those needs are then discussed with the PCT clinical nurse lead based at the home and the homes manager. If it is felt those needs can be met then admission is Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 11 arranged. Nobody is admitted to the home until a complete plan of support and care plan file is complied. The programme of care is developed by the PCT, as programmes identify specialist input such as plans of support by physiotherapist and occupational therapists. The manager is involved in the process to ensure that her staff can provide ongoing support and appropriate care delivery for the service users. The home is suitably equipped in terms of specialist rehabilitation facilities and equipment. This includes a large therapy room and an adapted kitchen for assessment prior to service users leaving Kirkley. There is a Service User Guide and a Statement of Purpose. However these documents were not seen as the senior carer and the administrator said the marketing department were currently updating both documents to include the details of the newly registered provider. A welcome pack is available in all rooms explaining the service the home offers. Service users spoken to during the visit all stated that they had received enough information about the home before moving in. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 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): 7, 8, 9 & 10 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 health, social and personal care needs of service users were being met by staff that respected their privacy and dignity. EVIDENCE: Service users are admitted to the home with a specialised programme of rehabilitation care that has been developed initially by the PCT staff based at MRI. On admission to Kirkley a further assessment is undertaken by the PCT staff based at the home and a care plan is produced. The assessment is an ongoing, continues process thought the service users stay. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 13 The care plans set out the reason why the service user has been referred for a service and set out the level of support they need to prepare them for their return home. They were detailed, informative and contained appropriate risk assessments to ensure service users are not put at any unnecessary risk. The care staff write in the daily progress notes and if there is any change in a service user they pass the information over to the PCT staff who will then review and update the care plan as necessary. The care staff spoken to said that they use the care plans as a working document and find they give enough information for them to assist in the rehabilitation programme. In addition to the care plan each service user has a white board in their bedroom that the PCT therapists keep updated to any specialist instructions relating to their rehabilitation programme. One member of staff said that they the white boards are very useful and informative for all staff. This ensure that service users are receiving the correct specialist care. Procedures relating to safe storage, administration and recording of medication were assessed and found to be in order. Where possible service users are encouraged to retain responsibility for taking their own medication when at Kirkley and are provided with safe, secure storage facilities in their own room. If a person is self administering their own medication the PCT nurses will undertake a risk assessment to make they are safe to so and are not put at any unnecessary risk. The medication procedures are overseen by the qualified nurses. Service users spoken to were all complimentary regarding the PCT and the care staff. One person said that coming to Kirkley has enabled them to go back and live in their own home. Another comment was ‘there is definitely a very high level of care given here, all the staff are great’. The staff and service users spoken to said that privacy and dignity is respected. This was also observed during the visit. From observations and talking to people during the visit it appeared that positive links have been established between the PCT professionals supporting service users and the staff employed by Inspirit Care Ltd. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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): 12, 13, 14 & 15 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. Daily life and social care arrangements meet service users assessed needs and support them in their preparation to move back home. EVIDENCE: From observations on the day of this visit and from talking to service users and staff the daily living arrangements are relaxed and service users are able to make choices around their day to day living. Service user’s daily activities are supported through planned therapy interventions and assessment programmes by qualified staff to aid their rehabilitation programme. From information received in the comment cards and from speaking to service users during this visit it appeared that they were happy with the choice and quality of meals provided. One comment was ‘the food is really lovely’ and when asked people said there was always a choice of meals. This was Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 15 confirmed by the cook. We were told that there is always a daily choice of fresh fruit and vegetables. There was a large bowl of fresh fruit and jugs of juice for service users to help themselves in the main lounge area if they so wish. The cook confirmed that if service users have any special dietary needs the qualified PCT staff discuss the specific needs directly with the catering staff to make sure that those needs can be met. This includes if people have any specific religious or cultural dietary needs. Service users are encouraged to maintain contact with family and friends and all staff and service users spoken to confirmed that visitors are welcomed at any time. The communal areas are spacious and offer comfortable areas for service users to come together to talk, take part in activities or watch television. There is a programme of planned activities displayed on service user’s bedroom doors. The activities are planned with the PCT staff and the home manager. Some of the therapeutic activities are organised by the PCT staff and the social activities are organised by the homes activity coordinator. The majority of returned comment cards indicated that there are always activities organised by the home and service users spoken to confirmed this. During this visit service users were seen taking part in armchair exercises in the morning and bingo in the afternoon. Some other activities advertised included supervised WII fit sessions, current newspapers, reminiscence sessions, films and anxiety management. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 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. Service users at Kirkley are able to raise concerns and are confident that they will be listened to. This means that people are protected from harm and abuse. EVIDENCE: There is a complaints procedure, which is included in the welcome pack in all bedrooms and it also displayed separately on bedroom doors to ensure service users know what to do it they have a concern or a compliant. All returned comment cards indicated that service users knew how to make a complaint and knew who to speak to if they are not happy. All the returned comment cards from staff indicated that they knew what to do if somebody wanted to raise a concern or complaint. One service user said he knew how to make a compliant but didn’t want to. He said ‘everything is great here I have no complaints at all’. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 17 The manager kept a record of all complaints as well as compliments received by the home. A large number of compliments were seen but the records of complaints were not seen as the manager was not on duty on the day of this visit and the senior carer and the administrator said that the record of complains and any investigations are kept secure by the manager. They did say that any the manager informs her line manager of any complaints received. This ensures that complaints or concerns are so that any patterns of poor practice can be identified at an early stage and fully addressed. No complaints have been received by us in relation to this service. To ensure that any allegations of abuse are correctly managed there was a copy of the updated local Safeguarding Guidance and the senior carer was able to describe the correct actions to be taken in the event of an allegation of abuse being made. To ensure people living at the home are protected from harm or abuse new members of staff cover safeguarding training as part of their induction. Staff spoken to said they had attended Safeguarding Adults training. We were told that all staff have received Safeguarding Adults training. However we were not able to see up to date training records to evidence this as the individual staff records were not up to date and the training matrix was currently being transferred to a new computerised system that was not available to view. No allegations of abuse have been made. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean, pleasant and suitable for its intended use as an intermediate care service. EVIDENCE: The home is well maintained and the design and layout provides a safe environment. The home was clean, tidy, well decorated and furnished to a high standard. There were no offensive odours and service users and staff spoken to all confirmed that the cleanliness of the home was always of a high Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 19 standard. The received comment cards also indicated that the home was always clean and fresh. The premises are homely and sections have been specifically adapted to ensure it offers therapeutic support and assessment areas such as the therapy room and the adapted kitchen assessment area. The grounds offer off road parking and a secure garden area to the back of the property. In addition to the large therapy room and the assessment kitchen there is a large lounge and dining room on the ground floor and a smaller visitor’s or therapy lounge on the first floor. There is an attractive reception area and service users were seen sat watching the comings and goings of the home. The atmosphere in the home felt relaxed and welcoming. Service users were chatty and staff were observed to have good relationships with them. There were policies and procedures relating to infection control and the senior carer confirmed that all staff have recently completed infection control training. There is also a modern matron from the PCT based at the home who acts as an infection control link. One of the rehabilitation assistants and one of the staff nurses are currently in the process of undertaking an infection control audit to ensure that the risk of cross infection is minimised. To reduce the risk of cross infections there are wall mounted alcohol gel, gloves and aprons throughout the home. Visitors to the home are request to use the alcohol gel on entering and leaving the home. There is also a thorough programme in place for cleaning wheelchairs and commodes. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are 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): 27, 28, 29 & 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. Service user’s needs are met by the numbers and skill mix of staff. EVIDENCE: A committed and stable staff team is employed with positive programmes of joint working with the PCT staff to ensure that service users receive a successful period of assessment and rehabilitation. From observations during the visit and from information supplied in the returned comment cards there is enough staff to meet the needs of the service users and this was confirmed by staff spoken to. There are rotas in place that show the number and grade of staff on duty. In addition to the staff employed by Inspirit Care Ltd there are PCT staff which includes staff nurses on duty seven days a week to ensure that service user’s needs are being appropriately met. The AQAA identifies that the recruitment process is thorough and all candidates are treated fairly and equally throughout the process. A sample of staff files Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 21 were looked at to see whether the required documentation was in place and if the necessary safety checks had been made. The files looked at contained the required documentation and safety checks. However it was seen that the files contained some photocopied documents that had not been signed to evidence that the original documents had been seen. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. Evidence was seen that a set interview assessment form is completed during the interview to assess knowledge and experience of the candidate. This is seen as good practice. The completed AQAA indicated that over 90 of care staff have successfully completed training in the National Vocational Qualification (NVQ) Level 2 or above. Staff spoken to confirmed that they are encouraged and supported to undertake the training. The senior carer confirmed that all new members of staff must attend induction training and evidence of this was seen in the staff files looked at. The majority of completed staff comment cards indicated that induction covered everything very well. The completed AQAA identified that there is a comprehensive training programme in place. However evidence of this could not be seen during this visit because as already stated in this report the individual staff training records were not up to date and the overall training matrix for staff was currently being transferred to a new computerised system that was not available to view. Staff spoken to and comments received in the returned comment cards indicated that they are supported and encouraged to attend training relevant to their job. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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): 31, 33, 35 & 38 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. Management and administration procedures ensure the service operates in the best interest of the people it supports. EVIDENCE: The manager has the necessary experience and knowledge to manage the home in the best interest of the service users. The service continues to deliver a sustained quality of care and support for people who require planned periods of rehabilitation and assessment. The Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 23 findings are that the outcomes for service users being supported are positive and meet the objectives of the service. Procedures for assessment, delivery of care and the management of the service are aimed at ensuring the service is run in the best interest of the people referred for support. Comment sheets are given to service users on discharge in an attempt to gain their opinion of the service being delivered. In addition to this the senior carer said that staff, including the manager, regularly talks to people on a one to one basis to seek their views. To further quality assure the service the AQAA identified that the new providers have appointed a quality assurance manager who will be working closely with the homes manger to develop systems that will enable the service to be monitored and success measured. The new providers are in the process of implementing their own policies and procedures to ensure they reflect current legislation and good practice advice, which staff will have access to. Where possible service users are encouraged to handle their own finances. Where this is not possible there are systems are in place for theri finances to be managed. The system was secure and records provided evidence of running totals for individual service users and included receipts for any purchases made on peoples behalf. The information provided in the AQAA demonstrated that the home’s maintenance certificates and fire records were up to date to ensure that people are not put at any unnecessary risk. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NA 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 OP29 Good Practice Recommendations It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4WH 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. Kirkley DS0000072943.V375014.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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