Care Home: Naomi

Similar services:

• Prinsted
• Elizabeth House
• Kenward House
• Boons Park
• Life Works Community Ltd
• Turning Point

What the care home does well The service is entirely led by the needs of the girls and their input into service development is given a high priority. There are regular house meetings, agreements as to individual responsibilities for every aspect of the project, including such things as menu planning, weekend planning, household duties and how leisure time is spent.NaomiDS0000023868.V377007.R01.S.docVersion 5.2The home is very clean, safe and comfortable. It is well furnished and the use of soft furnishings and colours provide an environment that is conducive to the rehabilitation process. The group work rehabilitation programme is very well structured so that the girls can get the most out of their stay in the project. The girls say that all of the staff give them really good support to take responsibility for their own lives and that this is helping them a lot in their recovery. Food services at the home are excellent. Good nutrition is seen as a very important part of the rehabilitation process. The girls input into menu planning and sometimes help out with cooking meals. The chef ensures that there are healthy and nutritious meals. There is a small and cohesive staff team who come from diverse backgrounds and experiences and bring this learning to the project for the benefit of the girls. What has improved since the last inspection? The environment has undergone a complete refurbishment that includes new bathrooms, carpets and curtains as well as a new wooden chalet in the garden to provide room for group work and office accommodation for the manager. The home now provides much needed services for women and has changed its name to reflect this change. The rehabilitation programme has become entirely group work based. The home has a new manager who is in the process of registering with the Care Quality Commission (CQC). The programme has a very low drop out rate. What the care home could do better: The home has worked extremely hard to set up the new project and is already providing a very successful rehabilitation programme. Therefore no requirements or recommendations were needed as a result of this visit. Key inspection report CARE HOME ADULTS 18-65 Naomi Rye Road Hawkhurst Cranbrook Kent TN18 4EY Lead Inspector Wendy Mills Key Unannounced Inspection 13th August 2009 11:00 Naomi DS0000023868.V377007.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. Naomi DS0000023868.V377007.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 Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Naomi Address Rye Road Hawkhurst Cranbrook Kent TN18 4EY 01580 752179 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) tthighgate@yahoo.co.uk Kenward Trust Post Vacant Care Home 9 Category(ies) of Past or present alcohol dependence (0), Past or registration, with number present drug dependence (0) of places Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Past or present alcohol dependence (A) 2. Past or present drug dependence (D). The maximum number of service users to be accommodated is 9. Date of last inspection 26th August 2008 Brief Description of the Service: Naomi is part of the Kenward Trust, the registered provider, with an administrative base at Kenward House at Yalding, near Maidstone. The Trust is a Christian organisation that provides rehabilitation services for people recovering from drug and/or alcohol addictions. The home was formally known as Highgate Hall and provided services for men. It now provides services solely for women. Naomi is situated in the centre of the village of Hawkhurst on the Kent/Sussex border, close to shops, churches, post office and pharmacy. There are local bus services that run near the home but the nearest main line railway station is five miles away. It is known locally as “The Naomi Project at Highgate Hall”. In 2008 the home was closed for refurbishment and opened again in April 2009 as Naomi. Naomi is a registered care home providing a new, first stage, abstinence-based, rehabilitation project for up to nine women. It offers an intensive, structured group work programme for women dealing with addiction and underlying issues. The rehabilitation programme is residential and for six months. The home is a large detached house. It has comfortable communal space with a lounge, dining room, group room and kitchen. All the people who use this service have single bedrooms. There are facilities for car parking at the front Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 5 of the building. To the rear of the home there is an enclosed garden with a grassed area and flower borders. The fees for this home are £690 per week. Additional charges may apply and are dependent on the assessed needs of the individual. Initial enquiries about the service should be made by letter, e-mail or telephone to: - Kenward Trust Central Administration, Kenward House, Yalding, Kent, ME18 6AH. E-Mail:- enquiry@ kenwardtrust.org.uk. Telephone 01622 814187 Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced and formed part of the annual inspection process of the Care Quality Commission (CQC). The inspection was carried out in accordance with the Care Standards Act and takes into account information we have gathered during this visit and information we have received prior to this visit. The information we have received prior to this visit includes information that the home that the home is required to give us, such as their Annual Quality Assurance Assessment (AQAA) and notifications about events that affect people who use this service; things that we have been told about the service from other sources such as relatives comments and the views of visiting health and social care professionals. The evidence we have gathered during the inspection process will result in the home being given a stare quality rating. During this visit important documentation, such as care plans, staff files, records of meetings and policies and procedures, was examined. The people who use this service we spoken to as a group to find out what they think of the home and the rehabilitation programme. Three staff members were spoken to in private and in depth discussion was held with the manager. A tour of the home was made in company with one of the people who use this service. The people who use this service say that they would like to be referred to as, “The Girls at Naomi” or, “The girls”. Therefore, this is the term that will be used to refer to them throughout this report. The Girls at Naomi said they are very happy with the support they are receiving and are very proud of the progress they are making. They spoke positively about the rehabilitation programme and the support they receive from the staff and the manager. The quality rating for this home is 3 Stars. This means that the residents experience excellent outcomes in all aspects of their support whilst living in the home. What the service does well: The service is entirely led by the needs of the girls and their input into service development is given a high priority. There are regular house meetings, agreements as to individual responsibilities for every aspect of the project, including such things as menu planning, weekend planning, household duties and how leisure time is spent. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 7 The home is very clean, safe and comfortable. It is well furnished and the use of soft furnishings and colours provide an environment that is conducive to the rehabilitation process. The group work rehabilitation programme is very well structured so that the girls can get the most out of their stay in the project. The girls say that all of the staff give them really good support to take responsibility for their own lives and that this is helping them a lot in their recovery. Food services at the home are excellent. Good nutrition is seen as a very important part of the rehabilitation process. The girls input into menu planning and sometimes help out with cooking meals. The chef ensures that there are healthy and nutritious meals. There is a small and cohesive staff team who come from diverse backgrounds and experiences and bring this learning to the project for the benefit of the girls. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 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. The home gives the people who use this service and their supporters god information about the service so that they can make an informed decision about embarking on the rehabilitation programme that the service offers. Thorough pre-admission policies and procedures are in place so that only those whose needs can be met are offered a place at the home. EVIDENCE: The statement of Purpose and Service User Guide have been reviewed and updated since the last inspection to reflect the changes made in the home. The Registered Provider, the Kenward Trust and the home give excellent information to prospective service users and their supporters. The Trust has over forty years experience of offering service to people with drugs and alcohol dependency. Information is readily available about this range of services. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 10 Good information can be obtained from the Trust’s website, or by telephone or letter. Naomi has its own section on the website. There were information leaflets in the foyer of the home giving specific information about the Naomi project as well as about other support services that people may move on to. The project has a very structured regime and there are some strict rules about behaviour whilst in the home, visitors, attendance at groups and, in particular, a zero tolerance of drugs and alcohol. Regular testing is carried out. The girls said that they understood these rules and the reasons for them. They said that the rules were made clear to them before they accepted a place on the project. They have signed contracts to agree to the rehabilitation programme and to say they understand the restrictions that the programme puts on them. Examination of rehabilitation plans confirmed that thorough pre-admission assessments are made before a place is offered at the home. Reports are obtained from care managers, social services and referring agencies. Copies of there were on file. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 11 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 & 9 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. The independence of the people who use this service is positively encouraged so that they can take as much responsibility as possible for their rehabilitation and recovery. EVIDENCE: The programme at the home is very structured and each day there is an opportunity for all the girls to express their views in a group setting. Some of the girls said that they found it difficult to express themselves in this way when they first came to the home but, as time has gone one, they have gained more confidence. They said that they felt they had been able to help shape the programme and that the manager and staff are always ready to listen to them and make changes if that seems the right thing to do. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 12 The girls said that they support each other when decisions need to be made. They are expected to take a great deal of responsibility for themselves and for supporting each other, especially at weekends. This means that they must elect a group representative, agree cleaning rotas, keep their rooms clean and decide who will do tasks such as shopping and cooking for the weekend. They must also agree how leisure time will be spent each week. The girls said that it took a while to get used to having to make some of the decisions but that, in general, they easily agree who should do what. One said, “Yes, it can be tempting when we have freedom and the shops where alcohol is available are so close but we know this is our chance and we don’t want to fail. We know we just can’t do it and we are looking forward to a better future”. Another said, “I’m proud of what I have achieved so far and I’m not about to give that up for one silly mistake”. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 13 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: 12, 13, 14, 15, 16 & 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. The home offers a full and structured rehabilitation programme that gives the people who use this service every opportunity to gain the strengths and skills to overcome their addictions. EVIDENCE: As previously mentioned, the programme is very structured and is entirely group work based. There is an extensive timetable that runs from Mondays to Fridays. Each day begins at 8.45am with a meditation and is followed by group on a variety of aspects of their recovery, including spiritual awareness linked to the twelve steps; group therapy to address addiction issues; personal goal setting; life skills and leisure activities. The formal programme ends at five O’clock each day but the girls continue to work on into the evening on Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 14 various assignments and attending Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings. Each group is facilitated by an experienced staff member. Family therapy is organised where appropriate, in conjunction with care mangers and family therapists. The girls said that they find the programme very hard work as they have come from lives that had become chaotic. Now they often continue to work on projects, write their objectives and do household tasks after the formal group work has finished. Each week there is a group leisure activity. The girls get together and agree and plan this activity each week. This includes making sure the activity is affordable. On the week before this visit the girls had gone swimming at a nearby leisure centre pool but the next activity they were planning was a trip to Thorpe Park. The home provides transport for some activities but for others the girls also use public transport. Examination of the care plans show that participation is carefully recorded and a strong emphasis is placed on the girls taking responsibility for expressing themselves in which ever way suits them. Some are very musical and express themselves well in this way whilst others are very artistic and some are more easily able to express themselves verbally. Some of their work was seen during a tour of the home and it was good to see how well the art work showed their progress. For example, one of the girls had made small posters to record the number of days that she has been free of substance misuse. Once the induction period has passed, the girls are expected to attend support groups, such as AA and NA meetings, outside the home. Because this is a first stage rehabilitation programme and, due to its intensity, there are restrictions on visitors to the home, particularly during the first month. After this visits are discussed and the amount of contact agreed. Within the agreed restrictions, visitors are made welcome to the home. The girls also make visits home if this is seen as helpful to their recovery. The home is situated on the main road in the village centre. It has always been seen as part of the community but the home is now working even harder to gain the support and understanding of the local people. Some members of the local community have already become involved with the home. One has offered religious support and another has offered lifts to meetings. Good nutrition and taking meals together are seen as very important aspects of the recovery process. Food services in the home are excellent. The dining room is light and airy. There are two chefs who share the kitchen duties from Monday to Friday. The main meal is taken at lunchtimes and menus are Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 15 agreed with the girls each week. Lunch was taken in company with the staff and girls at the home. The meal was tasty, well balanced and nutritious. Naomi DS0000023868.V377007.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 & 20 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. The home positively promotes the health of the people who use this service and gives them the skills to take responsibility for their own well being. EVIDENCE: All the people who use this service have written care plans in place. Care plans are important documents because they are one of the means by which people can be assured their needs will be met in an agreed and appropriate way. They are also an important source of reference for staff who must meet these needs in a consistent way. In addition they provide a way in which progress can be tracked and a basis for decision making for the future. Four care plans were selected for inspection. All the plans were up-to-date and contained good information about aspirations and any issues that might influence progress. There was good evidence that each of the girls is able to Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 17 input into their own plan of recovery. Health needs, religious and cultural needs and likes and dislikes are all recorded in the plans and there was good evidence to show that the girls are involved in developing their own plans. All the girls are registered with a local General Practice. The home is working closely with the practice to ensure that prescribed medicines support the rehabilitation process and are kept the minimum level needed. Medicines in the home are stored safely and securely. The home works hard to encourage the girls to take as much responsibility as possible for their own medication. However, as this is a first stage recovery programme from addiction, there are some necessary restrictions. Medicines are administered daily and the girls take responsibility for taking it at the correct times throughout the day. This is seen as a first step towards self medication. In many cases of addiction the abuse of a particular substance has meant that the individual has neglected to eat properly over a long period of time. Nutritional management in the home is excellent. The girls are involved with menu planning and take responsibility for meal preparation at weekends and sometimes on other occasions. They work with the chef to further their knowledge about nutrition and cookery. Naomi DS0000023868.V377007.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 & 23 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. The home actively seeks the views of the people who use this service and encourages their input to improve the programme at the home. EVIDENCE: The home has sound policies and procedures for managing complaints, concerns and safeguarding. Each week there is a house forum when the girls can express any concerns. All concerns and complaints are recorded and the notes of these meetings were avaialbe for inspection during this visit. The girls said that they can bring any issues to the house meetings and that the manager and staff listen to them and make changes when necessary. They said that they are supported and encouraged to take responsibility for finding solutions to their concerns as a group. The manager told us that there is a strong emphasis on individuals learning to take responsibility for their own actions and finding their own solutions to problems. The staff spoken to were clear about their responsibilities in respect of safeguarding vulnerable people and said they would have no hesitation in reporting any concerns. They said the manager listens well to concerns and takes action when indicated. Naomi DS0000023868.V377007.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): 24, 25, 27 & 30 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. The home is clean, well maintained and safe. This gives the people who use this service a pleasant and homely place in which to live. EVIDENCE: The home was completely refurbished last year and is now light, airy and well decorated and comfortably furnished. Good use of colour and fabrics created a calm and pleasant atmosphere. A tour of the home was made in company of one of the girls. She told us that all the girls take responsibility for keeping the house clean and tidy. It was god to note how well the girls have kept the house spic and span so that it is a welcoming and comfortable place to be in. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 20 All the girls have their own rooms. The bathrooms are clean and colour has been used to brighten them. There is plenty of communal space with a good sized lounge and separate dining room. The kitchen is large and has been fitted with stainless steel cupboards and work surfaces. It was spotless clean on the day of this visit and the chef is commended for the high standards she maintains. Outside there is an enclosed garden with a newly built wooden building that provides room for group work and the manager’s office. To the front of the home there is a gravel drive with parking facilities. Naomi DS0000023868.V377007.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): 31, 32, 33, 43, 35 & 36 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. There is a cohesive, well qualified and carefully vetted staff team who work closely with the people that use this service to help them through their recovery programme EVIDENCE: The staff team is all female to reflect the gender needs of the people who use the service. The role of support staff is to guide and help the girls through their group work and their recovery programme. The staff do not need to provide personal care for the girls but do need to supervise the administration of medicines. The home also uses volunteer support. Two part time chefs are employed to ensure that food supplies are ordered and that the main meals during the week are provided. As the programme depends on encouraging the girls to work as a team and to take more responsibility for themselves there is an expectation that they will Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 22 participate in household chores so that minimal housekeeping and maintenance input is required. Three staff files were selected for inspection. There is good evidence that all staff have received both statutory and specialist training. The staff come from a variety of experience and backgrounds. Some are qualified nurses, some have long standing experience of working with substance misuse and some come have trained as counsellors. All have received training in group work and counselling skills. The files also showed that all necessary checks had been made before employment was offered. Criminal records Bureau (CRB) checks are on file, two written references had been obtained and a full employment history is recorded. There are regular staff meetings; one to one supervision sessions and staff support each other with their work on a day-to-day basis. We spoke to two members of staff and one volunteer in private. All were very enthusiastic about the project and spoke positively about the way the staff work together. Naomi DS0000023868.V377007.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): 37, 38, 39 & 42 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. The home is well managed and run in the best interests of the people who use this service. EVIDENCE: The manager of the home has many years experience of drugs and alcohol rehabilitation. She previously worked at another home within the Kenward trust where she took on deputising duties. She holds a diploma in psychology and is an experienced counsellor. Currently she preparing her application to register with the Commission and is working to obtain the National Vocational Qualification at level four. Naomi DS0000023868.V377007.R01.S.doc Version 5.2 Page 24 The girls spoke very highly of the manager. One said, “She is strict but very fair, always explains the reasons why things are done the way they are. It’s good for us that she’s strict – we need it, especially when we first arrive”. Another said, “We can talk to he easily, she listens to what we have to say and things get changed if that is the right thing to do”. The staff said that the manager is well organised and enables the staff team to work well together. They confirmed that there are regular meetings with the manager at which they can share good practice and discuss any day-to-day matters that impact on the way the project runs. The management of the home is reviewed through monthly meetings between the Director of Residential Projects of the parent organisation and the manager. This ensures that any matters are addressed and good practice shared with other Kenward projects. There are plenty of opportunities for the girls to put their point of view. There are weekly house forums where ideas and concerns can be discussed as well as daily opportunities to deal with any issues that impact on life in the home. The manager completed the Annual Quality Assurance Assessment on time. This gave us very good information about the home and the progress to date. All records are stored securely and all documentation requested during this visit was up-to-date, in good order and readily to hand. There are weekly health and safety checks. Any maintenance or health and safety issues are noted in the maintenance book. Urgent health and safety issues are dealt with straight away and other repairs are carried out as soon as possible. No health and safety hazards were noted during a tour of the home. Naomi DS0000023868.V377007.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 4 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 3 28 X 29 X 30 4 STAFFING Standard No Score 31 3 32 4 33 4 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 4 4 X X 3 X Version 5.2 Page 26 Naomi DS0000023868.V377007.R01.S.doc NO 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. Refer to Standard Good Practice Recommendations Naomi DS0000023868.V377007.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. 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