Care Home: Normandy House

Similar services:

• Hillview Farm
• St Vincents
• Dalewood Respite Care
• Orchard,The
• REACH Upton Court Road
• The Cotswold Home
• Fairways

What the care home does well The home has a friendly, caring inclusive atmosphere in which the residents feel confident that they are very well cared for and their right to privacy and dignity is upheld at all times; this was clearly evidenced during the inspection. The home provides a relaxed friendly atmosphere, with a high standard of cleanliness throughout. The home deals with a number of diverse care needs and always ensures to offer a very personalised service to meet all the needs of those using the service. There is a very real commitment to ensure that all users of the Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 service, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. The home is committed to providing staff with ongoing training, to ensure they have the relevant knowledge and skills to address their clients diverse needs and to allow for personal development. What has improved since the last inspection? Since the last inspection undertaken in 2007, improvements have been made to ensure that service users monies are protected. Individualised receipts are now gained for service users purchases and service users/their representatives have agreed and consented to contribute to the purchase of fellow service users presents. The service had for some time been without a registered manager in place, however registration with the Commission has now taken place and the home has a registered manager in place. Information provided to users of the service has been reproduced in formats to suit their individual needs. What the care home could do better: Repairs highlighted within this report within the section headed Environment must be attended to as they are a potential hazard to those using the service. Where medication is to be administered covertly an interdisciplinary consultation must be undertaken with relevant health and social care professionals. The rationale for administering medication covertly, the consultation process, confirmation of the service user`s consent or their representative where they areunable to give consent, involvement of the service users representative and any risk management considerations must be documented. Key inspection report CARE HOMES FOR OLDER PEOPLE Normandy House 2 Laser Close Shenley Lodge Milton Keynes Buckinghamshire MK5 7AZ Lead Inspector Jane Handscombe Key Unannounced Inspection 5th & 6th May 2009 10:30 DS0000068996.V375553.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. Normandy House DS0000068996.V375553.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 Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Normandy House Address 2 Laser Close Shenley Lodge Milton Keynes Buckinghamshire MK5 7AZ 01908 673974 01908 673974 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) Caretech Community Services Ltd Mrs Deborah Ann Stephens Care Home 6 Category(ies) of Dementia (0), Learning disability (0), Old age, registration, with number not falling within any other category (0) of places Normandy House DS0000068996.V375553.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: Dementia (DE) Old age, not falling within any other category (OP) 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 21st October 2008 Brief Description of the Service: Normandy House is a large detached bungalow situated in a residential area of Milton Keynes. It can provide accommodation for six people. The home is registered to provide care for older people, people with a leaning disability and people with dementia. The home, initially registered in 2005, transferred to these premises in December 2006. Each resident has their own bedroom that has been decorated to reflect their individual tastes. The home has a lounge, kitchen/dining room and conservatory. There is also a garden area with seating and a barbecue. The fees for this service range from £1,431.70 to £1,471.00 per week. Normandy House DS0000068996.V375553.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 stars. This means the people who use this service experience good quality outcomes. This unannounced key inspection was conducted over the course of two days by Jane Handscombe and covered all of the key National Minimum Standards for care homes. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion and surveys were sent to people using the service, health and social care professionals and staff. Any replies that were received have helped to form judgements about the service. Information received by the Commission and any visits to the service since the last inspection were also taken into account. The inspection consisted of discussion with the manager, service users and staff, examination of some of the required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, service users and staff are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: The home has a friendly, caring inclusive atmosphere in which the residents feel confident that they are very well cared for and their right to privacy and dignity is upheld at all times; this was clearly evidenced during the inspection. The home provides a relaxed friendly atmosphere, with a high standard of cleanliness throughout. The home deals with a number of diverse care needs and always ensures to offer a very personalised service to meet all the needs of those using the service. There is a very real commitment to ensure that all users of the Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 6 service, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. The home is committed to providing staff with ongoing training, to ensure they have the relevant knowledge and skills to address their clients diverse needs and to allow for personal development. 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. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 7 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 Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 8 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): 1 and 3. Standard 6 is not applicable to this home. People using the service experience good quality outcomes in this area. Prospective users of the service are provided with a full assessment of their health, social and personal care needs prior to being offered a place, to ensure that both parties are confident that their needs can be met appropriately. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: At the time of this inspection the home was at full capacity with six service users and no vacancies. We were informed that there have been no new admissions since our last visit. We discussed the admissions procedure with the registered manager who informed us that prospective users of the service are provided with a full Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 9 assessment of needs prior to moving into Normandy House, information about the home in the form of a service users guide and initial visits to the home to meet with fellow service users and staff, to ensure that both parties are confident that their needs can be met appropriately. The last Key inspection evidenced that there was a good assessment procedure in place and people’s needs were thoroughly assessed prior to moving into the home. The service have acted upon a recommendation made during the last key inspection and a thematic inspection undertaken in May 2008 in producing the service users guide in a format that meets with people’s individual needs ensuring that they are now accessible and understood. Each service user has been provided with their own copy and had it explained to them. Information about the service is also provided in the home’s Statement of Purpose, however it was noted that there was some contradiction about the number of service users accommodated in the home. The service is registered to accommodate a maximum of six service users yet the information within the Statement of Purpose gave information about the number of service users being twelve. The registered manager was unaware of the misprint and assured us that this would be rectified. During this visit we case tracked two people’s care and it was noted that their files did not contain their assessments that had been undertaken prior to them moving into the home, they had been removed from their files and archived. The manager was reminded that it is an expectation that the registered person ensures that people’s files contain evidence that an appropriate assessment is undertaken before they move into the home. Steps were taken to ensure that they be removed from the archives and replaced into people’s files. Feedback from satisfaction surveys sent to those using the service informs us that all those using the service received enough information to help them decide if the home was the right place for them, before they moved in. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 10 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 and 10 People using the service experience good quality outcomes in this area. Every user of the service has a care plan in which their health and personal care needs are identified and details the actions required to meet them ensuring their care needs and health requirements are met appropriately. Personal care and support is offered in a way that promotes and protects service users’ privacy, dignity and independence. Medication is well managed, ensuring that service users receive the medicines they require to keep them healthy and well. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 11 A comment card completed by a community nurse, indicated satisfaction with the overall care and support provided at the service. She informed us that the service works in partnership with health professionals always seeking advice and acting upon it to meet people’s needs and improve their well being. She indicated that the service provides ‘very personal individualised care to each client…clients are very well cared for…..excellent provider of services for these clients’. During the inspection we viewed a sample of care plans and found them to be individualised and contain appropriate information on the users’ individual needs and preferences and how these needs are to be addressed. We were informed that a new care planning format has been produced, which is to be implemented once the staff receive guidance in completing the new paperwork; the manager, her deputy and a senior carer have received training enabling them to cascade the training down to the remaining care staff. The manager is very positive about the new format and explained that it will be much more person centred and is positive on implementing the change. Care plans are drawn up and reviewed regularly with the involvement of the service user themselves together with family/representatives and other relevant health and social care professionals. Service users have the necessary equipment they require to enable them to maintain their independence and robust risk assessments are in place detailing how the care is to be delivered in a safe manner whilst maintaining and promoting the users independence. Of those service users being case tracked during the inspection it was evident that the carers spoken to were aware of their individual needs and had a good understanding of how to address their needs whilst promoting their independence. The healthcare records were in good order and included separate records of contact with various healthcare professionals. The records indicated appropriate regularity of appointments and appropriate one-off consultations where necessary. Records show that service users weights are monitored and routine health screening is provided, such as chiropody, dental check ups and dietician input where necessary. The home has effective systems in place to manage medication; each service user has an individual medication profile detailing the medications to be administered, what the medication is for and possible side effects. Medicines are stored securely in a locked medication cabinet which is fixed to a wall. Medication is supplied to the home in blister packaging by the pharmacist, who undertakes a medication audit annually. The service themselves undertake a weekly audit, which is undertaken by two staff and the District Nurse visits once a week, during which she checks the medication administration records. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 12 All staff are provided with medication training and have their competencies checked on a six monthly basis. Samples of medication administration records were viewed as part of our case tracking; the medication administration records were completed and were signed appropriately. It was noted, whilst inspecting a service users file that medication was being administered covertly. There was documentation within the service users file which had been signed by the District Nurse advising that the medication be administered in this way due to the service users’ lack of capacity and his/her refusal to accept the medication which, if the medication was not administered, would be detrimental to his/her health and welfare. The registered persons needs to ensure that best interest decisions are discussed and agreed with the multidisciplinary team and the persons relatives or advocate and documented within the file, to which the manager agreed to undertake. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 13 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 and 15 People using the service experience good quality outcomes in this area. Service users are enabled to keep in contact with family and friends, to maintain important social contacts. People using the service are provided with nourishing meals, which are freshly cooked on the premises. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Service users are consulted on and are encouraged to participate in all aspects of the home with staff assistance as needed. The records show that monthly meetings are held with all those using the service during which discussions take place around what activities they would like, the choice of meals and places of interest that they would like to visit. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 14 During the first day of this visit, two users of the service were at a local day centre, two had gone shopping and visited the hairdressers with their carers and two remained in the home. The service has recently acquired a minibus with suitable facilities for wheelchair users, to enable greater access to the community and to take service users out on trips to places of interest. Whilst the acquisition is very new, the manager explained that day trips have initially been planned to allow users of the service to get used to travelling in the minibus as a group, since formerly a taxi service was used. Two users of the service are reluctant to using the minibus and apprehensive about participating. The manager explained that initially they are concentrating on short trips and day trips with the intention of gradually building them up to enable people to enjoy the option of short weekend breaks and holidays where required. People completing comment cards said that the home arranges activities that they can take part in if they wish. People make use of local day centres and groups depending on their interests. One healthcare professional who completed a comment card indicates that individuals using the service are supported to live the life they choose wherever possible and the service ‘ensures the clients are able to maintain activities of daily living for as long as possible’. He/she further informs us that the service is very good at engaging them in various activities. Arrangements for service users to meet with friends and family members are flexible and support is given to maintain personal relationships where required. Service users are able to receive visitors at the home, there are no restrictions imposed on visiting unless requested by the service user themselves. Service users are able to entertain them in their own bedrooms or in the communal areas of the home. One visitor was visiting their son during this visit and informed that she is made to feel welcome at all times, is encouraged to be involved in his care and finds the staff very accommodating. People who use the service are provided with good quality food, which is freshly cooked on the premises and are offered a choice. Special diets are available to meet residents’ health and cultural needs. The service endeavours to take individual tastes into account and discusses their preferences with them during their one to one talk sessions and in their monthly meetings. The menu is changed on a weekly basis and all those using the service are encouraged on taking part in planning the menus. The daily menu is made accessible to all those using the service and is provided in picture format, to meet their individual needs. During this visit we chose to join the service users for lunch, which was provided around the kitchen table. The meal consisted of meatballs and mashed potatoes followed by fresh fruit or yoghurt. The mealtime was Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 15 unrushed and staff were observed to help those who required assistance with sensitivity. Normandy House DS0000068996.V375553.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 and 18 People using the service experience good quality outcomes in this area. Effective complaints procedures are in place to ensure that issues raised by service users or their representatives are listened to and acted upon in a timely manner. Adult protection is appropriately managed to ensure that service users are not placed at risk of harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Service users and their family members/representatives are provided with copies of the complaints procedure and are confident that any concerns or complaints they may have would be listened to, taken seriously and acted upon appropriately and if the need arose would use the procedure. The procedure is provided in a format suitable to people’s individual needs. The home keeps a complaints log to record any complaints received in which they record details of the actions taken in response to the complaint/concern Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 17 and the outcomes. The manager informs us that no complaints have been received during the last 12 months. Users of the service have regular monthly one to one talk times that help them to share their views and any concerns that they may have as well as discussing aspects of their health, social and personal care needs.. Within the entrance there is a suggestions box in which users of the service, visitors to the home, staff and service users representatives can at any time post any suggestions or concerns and are able to do so anonymously if they wish to remain unidentified. All service users are protected form abuse, neglect and self harm and have all been provided with guidance and support in understanding safeguarding issues. All staff are provided with relevant training both in their induction training and regularly thereafter, enabling them to recognise the signs of abuse and how to respond if an allegation or incident is brought to their attention and are all provided with and understand their responsibility to use the homes ‘whistleblowing’ policy if the need should arise. Safeguarding is a standing agenda item discussed in staff meetings and in one to one supervisions, which is very good practice. There has been two safeguarding issues, during the period under review, both of which were dealt with appropriately and investigated in line with the local interagency safeguarding policies and procedures. Normandy House DS0000068996.V375553.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): 19 and 26 People using the service experience adequate quality outcomes in this area. The home is suitable for its purpose but there are some shortcomings in relation to providing a safe well maintained environment that need attending to, to ensure the health safety and welfare of those using the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Normandy House is located in a large residential estate a few miles from the centre of Milton Keynes. It is indistinguishable as a care home and blends in with other properties in the area. There is limited parking at the home. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 19 There is a communal lounge and conservatory for the users of the service to enjoy. The Conservatory doubles up as a quiet room with sensory equipment, which service users enjoy when they feel the need to reflect or be alone. There is a well kept garden which is accessed from the conservatory via a ramp for users of the service and their visitors to enjoy during the warmer summer months. The garden is equipped with a bird table, barbeque, tables and chairs. The garden is generally secure, however during this visit it was noted that the garden fencing to the rear of the garden was in a bad state of repair; fencing panels were very damaged and had fallen over into the neighbours garden. This needs to be remedied to ensure the health, safety and welfare of those using the service when accessing the garden. A tour of the home found it to be clean, homely and domestic in style with no unpleasant odours. Service users private bedrooms were clean and personalised with their own posessions and pictures in place. All rooms are provided with en-suite facilities. Generally the home provides an environment, which meets the service users needs, however there were a number of shortfalls, which could compromise the safety of those using the service; a number of bedrooms (four in total) require window restrictors, the registered manager is aware and informs us that she has reported this shortcoming to the maintenance department of the organisation, and is awaiting them to contact her to arrange a date to affix them. It was also noted that a large number of rooms failed to have radiator guards, this was an area which the service had highlighted themselves in their completed AQAA and informed us would be completed within a month. However this has not yet been attended to; the lack of radiator guards does not act in the best interests of the service users health and safety and could potentially place them at risk of harm. One service users emergency pull cord is not accessible to him, it is placed on the other side of the room. The registered manager assured us that this would be moved to ensure that the service user has the means to call a member of staff in an emergency situation. The hot water to the basin in the communal WC, to which service users have access, posed as a risk to people using the service in that it was very hot to the touch. When we recorded the temperature, we found it to measure 63ºC for which an immediate requirement was made requiring the registered person to ensure appropriate risk assessment be undertaken and plans be put in place to reduce the risk with immediate effect and to further ensure that hot water in the communal WC be regulated and maintained at a level of 42ºC or below by the means of either a pre set valve or other means. The manager took immediate steps to protect users of the service from harm; she place a notice on the door to the WC warning people that the door had been locked due to a health and safety issue and to contact a member of staff for access. She informed service users of the risk and suggested that they use their en suite facilities in their bedrooms. We have since received confirmation that a pre set Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 20 valve has been installed, within the timescale given, to ensure that hot water is delivered at the required temperature. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 21 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 and 30 People using the service experience good quality outcomes in this area. Robust recruitment practices are in place, to ensure that service users are protected from harm. Systems are in place for inducting, supporting and training staff, ensuring that care needs are recognised and met by a skilled work team. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During our visit we viewed two staff files, one of who is a recently recruited member of staff. Evidence within the files and a telephone conversation with the HR department evidenced that the home has a good recruitment procedure to ensure that suitable staff are employed to look after their vulnerable clients. Relevant pre-employment checks are undertaken, references sought and face to face interviews undertaken to ensure their suitability to work with vulnerable adults. Whilst the recruitment documentation is held in the HR office, the staff personnel files held in the home should contain a declaration signed and dated by the registered manager that she has seen all the relevant Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 22 documentation listed in the Care Home Regulations and dates they were obtained. The registered manager assured us that this would be actioned. Evidence viewed within staff personnel files informs us that members of staff undergo induction training, upon appointment to their posts, and are offered ongoing training, which equips them to meet the assessed needs of the residents within the home. Likewise feedback gained from staff members informs us that they were all provided with an induction programme and four of the five completed questionnaires tell us that the induction they were provided with covered everything very well and they are being provided with training that is relevant to their role. The home has a good programme of training in place for staff. The staff records viewed contained evidence of induction training, all relevant mandatory training and ongoing training that has been undertaken, to ensure that they have the skills and knowledge to undertake their roles competently. Information provided to us in the AQAA informs us that of the eleven permanent care staff, ten have attained National Vocational Qualification (NVQ) in Care at Level 2 or above which is above the 50 recommended by the Commission and is commendable. Staff are provided with supervision and support on a regular basis, which is documented within their personnel files, this was further confirmed from feedback from carers themselves. The home engages regularly with users of the service to gain feedback on the service it provides; this is undertaken on both an informal and formal basis through feedback from annual surveys, noting any comments or concerns when undertaking residents care reviews, resident meetings and one to one talk time The home deals with a number of diverse care needs and always ensures to offer a personalised service to meet the individual needs and preferences of their service users. There is a commitment to ensure that all users of the service, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 23 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 and 38 People using the service experience good quality outcomes in this area. The management and administration of the home aims to promote continuity and good overall personal care for the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection a permanent manager has been appointed and undergone registration with the Commission. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 24 The registered manager is experienced and competent to manage the home, she has attained NVQ levels 2, 3 and 4 in care and is currently registered to undertake the Leadership and Management in Care Award this month. The course was originally due to start in April, however this was cancelled and rescheduled. She has a good understanding of the day to day running of the home but needs to become confident in work with the legislation. The home does not have access to the internet and should be an area that the organisation considers as this would allow the manager to update her knowledge on the relevant legislation and provide her with the added skills and knowledge. Service users and staff spoke in complimentary terms about her management ability and the support she gives. The home has a health and safety policy statement and provides training and equipment for staff. We discussed health and safety issues and saw appropriate maintenance records relating to maintaining a safe environment for residents. Regular safety checks are undertaken relating to fire safety and infectious diseases and regular servicing and maintenance of equipment, all of which were seen to be documented appropriately. The registered provider visits the home regularly and monitors standards which includes examining care plans, fire log training procedures, the administration and recording of medication and other health and safety issues and speak to residents and care staff alike to gain their views on the standard of care provision. These visits undertaken are in line with Regulation 26 of the Care Home’s Regulations and records are kept of each visit. The home does not act as agent or manage monies on behalf of residents, however there are systems in place to ensure that residents’ personal allowances and small amounts of cash are safely managed and there are receipts and records for all transactions. Generally the health, safety and welfare of those using the service and the staff delivering the care are protected, however there are some environmental issues that need addressing which have been mentioned within this report and for which requirements have been made (see section headed environment) The home sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for. The AQAA contains clear, relevant information that is supported by a wide range of evidence and informs of areas in which they plan to make improvements over the next 12 months. Normandy House DS0000068996.V375553.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 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 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 2 x 2 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 3 x 3 x 3 x x 2 Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13(4)(a) Requirement Accommodation is to be improved as indicated in the report to remove risks to those using the service and to ensure their health, safety and welfare Timescale for action 30/06/09 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 Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 27 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). 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. Normandy House DS0000068996.V375553.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!