Care Home: Nottingham Neurodisability Services Aspley

What the care home does well People who consider living at the service have a very thorough and detailed pre-assessment of their needs completed, before a placement is offered. This process considers all the factors that impact on the person`s life and includes information from any professionals already involved with the person. The service is able to meet people`s complex physical and psychological needs as well as managing behaviour that may be challenging. Staff numbers are decided by the assessment of people`s needs and people can be provided with one to one support if required. People`s views are listened to and concerns are noted and investigated as necessary to safeguard people living in the home. The range of activities available to people is extensive and purposeful, providing people with meaningful occupation. During our visit we observed competent and trained staff who were consistently meeting the needs of people who live at this home. What has improved since the last inspection? Three requirements were made at the last key inspection. These related to reviewing of care plans, a repair to the lift door and locking of laundry and storage room doors. These had all been met and the standards maintained. A recommendation had been made and this had also been implemented. There is a programme of re-furbishment and a number of areas have benefited from re-decoration. What the care home could do better: The re-furbishment programme needs to continue to ensure that the standard of decoration throughout the home is maintained. The specially adapted kitchen area on the first floor would benefit from being re-fitted. Key inspection report CARE HOME ADULTS 18-65 Nottingham Neurodisability Services Aspley Robins Wood Road Aspley Nottingham NG8 3LD Lead Inspector Angela Starr Key Unannounced Inspection 3rd July 2009 09:00 Nottingham Neurodisability Services Aspley DS0000059536.V376310.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. Nottingham Neurodisability Services Aspley DS0000059536.V376310.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 Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nottingham Neurodisability Services Aspley Address Robins Wood Road Aspley Nottingham NG8 3LD 0115 942 5153 0115 942 5154 aspley@fshc.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Four Seasons Homes (Ilkeston) Ltd Ms Colette Manning Care Home 32 Category(ies) of Physical disability (32) registration, with number of places Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2008 Brief Description of the Service: Aspley Neurodisability Unit is a purpose built unit situated in the inner city area of Nottingham, providing health and personal care for up to 32 adults. A variety of communal areas are available which include lounges, activities rooms and a dining area on the first floor. All bedrooms are on the ground floor. A lift is provided. The home is within access to local shops, library, health centre, churches and a pub. The fees currently charged at the home start at £650 per week depending upon individual needs. Additional costs for hairdressing, newspapers, toiletries, holidays and chiropody intervention are charged as extra. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use the service experience good quality outcomes. The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people who use the services and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. We ask managers to fill in a questionnaire called an Annual Quality Assurance Assessment, which tells us how well their service provides for the people who use it and how they intend to improve their service. We received this back from the manager within the required timescale and we used the information it provided us with to assist in planning our visit and deciding what areas to look at. We also reviewed all the information we have received about the service since we last visited in July 2008 and we considered this in planning the visit and deciding what areas to look at. The main method of inspection we use is called case tracking which involves us selecting a number of people who use the service and looking at the quality of the care they receive by speaking with them, observation, reading records and asking staff about their needs. We spoke with 4 staff on duty, the manager, 3 people who use the service and 1 relative to form an opinion about the quality of the service being provided. We also read documents, and medication was inspected to form an opinion about the health and safety of people who use the service. A copy of the latest inspection report can be found by visiting the Care Quality Commission web site at www.cqc.org.uk Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed prior to admission to the service which ensures that each persons needs can be met. EVIDENCE: The manager told us in the written information she provided, We make all prospective clients welcome and show them and their families around. We make pre-assessment visits to clients to assess their needs and ensure that we can meet those needs.” She told us that each person has a thorough and robust pre admission assessment completed to ensure that their needs can be met at Aspley. This is done prior to any placement being offered. The files we saw all contained a copy of this assessment and a thorough and detailed care support plan which had been developed with the person within the first week of them living at the service. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 9 These plans were comprehensive and detailed enough to provide staff with all the information they required to enable them to deliver the appropriate care in the manner preferred by each person. We looked at the information given to people when they make an initial enquiry. This included the statement of purpose and service user guide. Both of these documents were displayed in the entrance hall, along with a copy of the last inspection report and the complaints procedure. The manager told us that the Service User Guide is due to be revised and this will be done in conjunction with the people living at the service and will include pictures. People we spoke with told us “I chose to come here. I’ve tried other places but this is the best for me.” A relative said “We came to look round and were made very welcome.” Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the service have their personal and health care needs assessed and met in the way they prefer. EVIDENCE: The manager told us in the written information she provided “We enable clients to live the lifestyle of their choice as far as possible, choosing the time they go to bed, get up, what they eat and activities.” The documentation we looked at showed us that care plans were developed in a person centered manner. Dignity and respect had been considered throughout and where appropriate a person’s mental capacity had been assessed and taken into consideration. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 11 As part of our case tracking process we looked at the care files for three people who live at the service. All three files contained detailed and comprehensive care plans which had been developed and reviewed in conjunction with the person and their relative as far as possible. Throughout the care plans there were references to peoples choices and needs. One person told us “I know about my care plan. It’s what I want.” Relevant risk assessments were in place and were reviewed and up to date. The risk assessments we saw provided evidence that people are encouraged and supported to take acceptable risks and make decisions that enable them to maximise their independence. “I wanted to go on holiday and the staff helped me to sort it out.” Care files also provided evidence that people have access to community facilities for dental care, optical care and that their health needs are met by Doctors and Specialist Practitioners where necessary. People told us that staff enable them to go out to the dentist or optician whenever possible but the optician visits the home as well. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Aspley experience a fulfilling life as far as is possible. Individual goals are identified and people are enabled to make choices and exercise preference. EVIDENCE: The manager told us in the written information she provided “Clients engage in a full activity programme in group and individual sessions. We have two activities staff that provide sixty hours of cover over seven days.” On the day of the inspection we observed people engaging in a variety of activities. These included a group who were reading and discussing newspaper articles together, a person doing a jigsaw puzzle, people enjoying a pet Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 13 therapy visit and we observed one of the staff spending time with a person in their room on a one to one basis. We spoke with one of the activity co-ordinators who told us that the programme is extensive and is formulated to include everyone who wishes to engage in any activity. He told us “We have really pulled out all the stops this year and many people are going on holidays” “Everything we’ve needed for people has been provided.” One person we spoke with told us they have been to Butlins and had a great time. They didn’t want the holiday to end. Another person told us they are going to Blackpool and were very excited about it. The activities include music therapy sessions, pet therapy, arts and crafts, quizzes and numerous other activities. Day trips are a regular feature and this year, people have been to Crufts dog show, the Tate Gallery in Liverpool, Warwick Castle and the Sea-life centre in Birmingham. Each Friday, staff from South Notts College visit to teach art and crafts to some of the people living in the home. This is done with a different topic each term and people may be awarded a certificate to confirm their achievements. The service also benefits from having an adapted kitchen where people can take part in cookery sessions. They have recently prepared a Sri Lankan meal. Regular residents meetings are held where people have opportunities to discuss and suggest anything they would like to do. This is also used to gain feed back about the previous activities. These meetings are minuted and we saw evidence that peoples suggestions and requests had been followed up by staff. People we spoke with told us that there is always something interesting to do and lots of places to visit. People told us that the food is very good and “there is plenty of it.” “I’ve put weight on.” “I have whatever I want.” The main meal is served in the evenings to suit the preferences of the people living at Aspley. People told us that this was their idea and choice. There is a supper menu available as well. We observed people having their lunch and where staff were providing assistance, this was given in a discreet and sensitive manner. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 14 Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are receiving personal and healthcare support in the way they prefer and require. Their health care needs are being met. EVIDENCE: From the pre- assessment, a thorough and detailed care support plan is developed with the person within the first week of them living at the service. We case tracked three people who live at the service and looked at their care files. All contained thorough support plans that had been reviewed each month and any identified changes addressed. There was evidence in all the files that people had been consulted as far as possible about their care and how they would prefer to be supported. People we spoke with told us “I helped with my care plan and decided what I want and how I want it.” Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 16 “The doctor comes every week and if I need to see him I just tell the staff.” The manager told us that the service has a contractual arrangement with a local GP surgery whereby the same Doctor is responsible for the health care of the majority of the people living at Aspley. The only exceptions are because people have chosen a different Doctor. This arrangement means that the doctor routinely visits the service once a week and has established good relationships with the people living at the service and with the staff. This enables a seamless and efficient service for people. Files showed us that people are accessing specialist medical services as their needs require. An optician visits regularly and one person told us that they have recently had new glasses. People are enabled and supported to attend appointments in the local community, such as the dentist. Individual staff members have received training in areas such as infection control and continence and have then taken on a specialist ‘link’ role within the service. This has enabled the service to build good relationships with a variety of external specialist services that advise and support the staff to fulfil their role. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Aspley are protected from potential abuse and harm. There are robust policies and procedures in place that are understood and followed correctly by the staff team. EVIDENCE: The written information provided to us by the manager tells us “We listen to all complaints and respond within the guidelines laid down in company policy. Staff are trained to deal with concerns and complaints and complete documentation as required.” “A member of our staff team has received training in order to train other staff in ‘Safeguarding Adults’ and to provide support in their learning.” (Safeguarding Adults is a process of identifying and reporting suspected or potential abuse of vulnerable people and provides a framework of consistency to protect those individuals at risk.) “We encourage clients and their families to raise concerns.” The complaints procedure was prominently displayed in the reception area and is included in the Service User Guide. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 18 People we spoke with told us that they know how to complain and would be confident to do so. “I could tell the manager anything. She’s very good and I know she would put things right.” “You can tell the staff things and know they will sort it out for you.” People also told us that the manager talks to them all on a one to one basis and their individual problems are sorted out immediately. A relative we spoke with said that they had raised a few issues when their relative first came to the home but they were sorted out and have not happened again. They had not felt that they needed to make a formal complaint. Regular residents meetings take place and people told us that they can use this to talk about anything they are concerned about. Minutes of these meetings showed us that any issues are recorded and a response is given at the next meeting. Records we looked at showed us that there have been ten complaints since the last inspection and that all were resolved and the outcome shared with the complainant. Seven of these were upheld and the appropriate actions were taken. Training records we looked at showed us that staff have received training in Safeguarding Adults and when we spoke with staff, they were able to demonstrate a good level of knowledge and understanding. One member of staff said “The staff here know what they are doing.” “People living here are safe.” Staff records showed us that people are protected by the implementation of robust recruitment procedures ensuring that all necessary references and checks are completed satisfactorily before anyone commences employment. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that is appropriate to the needs of the people living at the service and it is well maintained. EVIDENCE: The written information provided to us by the manager tells us “We provide a safe, comfortable and homely environment. Our documentation is kept up to date with reference to environmental health, health and safety and cleaning schedules.” All fire safety checks are completed and up to date. Staff we spoke with have all had fire safety training and know about the services evacuation procedures. A full time handy person is employed and records are kept of all safety checks Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 20 including Legionella, etc. We saw the site maintenance reports that told us regular safety audits are carried out and all required testing is valid and up to date. We looked at the maintenance book and it showed us that any tasks that are identified are recorded by staff for the handyman to see. When the task is completed he signs the book. Staff we spoke with told us that they know how to report any faults or problems and that repairs or replacements take place very quickly. We undertook a partial tour of the home where we looked at communal areas, kitchens, bathrooms and some people’s bedrooms. Bedrooms were located on the ground floor and those we observed were personalised and several had been decorated since the last inspection. People told us that they had chosen the colours and have all their personal items around them. The communal areas are on the first floor and are accessed by a lift or staircase. We observed that some people were able to use the lift unaccompanied and risk assessments were in place with regard to this. There is a large lounge with television and music centre, a dining room, activities room and a small lounge designated for smokers as well as a smoking area outside. The gardens included raised beds where people can grow vegetables or flowers. On the day of the inspection, the handyman was undertaking a number of tasks in the garden. Some people have their own gardens that can be accessed through their bedroom patio doors. The laundry facilities appeared to be well organised and managed and measures were in place for minimising spread of any infection. People we spoke with told us that they have not had any problems with laundry. Since the last inspection many areas have benefited from re-decoration and some refurbishment. The activities room is spacious and bright and provides a light and airy environment for people. Nottingham Neurodisability Services Aspley DS0000059536.V376310.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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by competent and appropriately trained staff who are able to meet people’s assessed needs. By staff following robust recruitment policies and procedures people are protected from potential harm and abuse. EVIDENCE: The written information provided to us by the manager tells us “We are very good at supporting staff and have an excellent retention rate. We manage staff sickness and absence, provide training and our duty rota is decided around the assessed needs of the people living at Aspley.” The manager is always supernumery as are the activities co-coordinators. Activities coordinators are employed for a total of sixty hours per week and cover seven days. There is an extensive training programme in place and this includes mandatory Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 22 training as well as a number of courses that are specific to the skills required for some of the complexities and challenges that occur on the unit. We looked at the files for three members of staff. All contained references and evidence that the relevant checks, such as Criminal Record Bureau and Protection of Vulnerable Adults, had been completed before they commenced their employment. Staff confirmed that they had not commenced employment until all these were in place. There was information about the registration of nurses with the Nursing and Midwifery Council and this was up to date. We spoke with three staff members and all said that they had undergone a period of induction when they first started work and had completed all mandatory training. Records we looked at confirmed this. Records also showed us that staff have continued to work towards completing additional training such as first aid, nutrition, infection control, and that further training had been arranged. Staff spoken with said they were able to discuss relevant issues in meetings and individually with senior staff when needed. The majority of staff hold a nationally recognised care qualification at various levels, and other staff are working towards the qualification. We asked staff about their knowledge of Safeguarding Adults and Whistle Blowing and their responses told us that they do understand and work by these policies and procedures. One staff member added “The people that live here are safe.” One staff member we spoke with told us “They will always provide training and are very supportive.” “I always feel part of the team.” Another staff member said “Training is good. There is regular training every month and we can request more if there is something we want to do.” Staff meetings take place at regular intervals and these are always minuted. We looked at records of these meetings and saw that Health and Safety and training are discussed at each meeting as well as other agenda items that are relevant at the time. Staff told us that there is always an abundant supply of gloves and aprons and they were not aware of these supplies ever running out. The staff duty rota showed there were two nurses and five care assistants on duty during the day and one nurse with three care assistants overnight from 8pm to 8am. People we spoke with said that there were enough staff available to meet their needs. The manager told us that staff were not available to assist with bathing while they were serving supper, but everyone’s choice of when to take a bath or shower was taken into account and met at other times. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 23 During this inspection visit we observed that staff responded to people’s requests for assistance as required. There were records of formal staff supervision meetings and observations of their practices. Staff spoken with confirmed that these are taking place and that they found them useful. Staff we spoke with told us that they enjoy working at Aspley and feel supported by the manager. They confirmed that they undertake a variety of relevant and useful training and access to such is encouraged. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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 service benefits from having an experienced manager in post who encourages people to be actively involved in the running of the home. She ensures the health, safety and welfare of people living at the service and of the staff. EVIDENCE: The Annual Quality Assurance Assessment was completed by the manager and returned to us within the required timescale. It was completed in a manner that addressed all the key outcome areas and provided us with some useful information about the service. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 25 Records showed us that the manager has many years experience as a registered nurse in hospitals and rehabilitation services as well as managing care homes. As part of our case tracking process we looked at files of three staff members. All had records of supervisions and training. Staff we spoke with told us that they feel supported and listened to by the manager. “I have one hundred per cent support from my manager.” “This home is well run and is all about the people that live here.” Another member of staff said “From the management down, this home is well run.” A relative we spoke with told us “We met the manager when we came to look round and we were made to feel very welcome.” “When I have had cause to speak to the manager about anything it is acted upon immediately.” “I am always contacted about anything of concern with my relative.” People we spoke with told us that there are always enough staff on duty and they are not kept waiting to have call bells answered. Staff told us that they feel there are enough staff to meet people’s needs and whenever there are activities outside the home, more staff are brought in. People we spoke with who live at the service told us that they do feel listened to and that their opinions are always taken into account. One example given to us was about having the main meal in the evening to suit people who wish to go out during the day. During our visit we saw that the manager has developed an internal quality assurance system, the aim of which is to gain feedback from people living at the service, relatives and other relevant parties about the quality of the provision. This comprises of questionnaires, resident meetings and any comments made by visitors to the home. The information gathered through this process informs the manager of areas which require attention and improvement. There was a fire plan in place and training and regular practices were carried out for staff. Staff told us that in the event of a fire alarm sounding they would assess and take action to move people to safe areas. They would not evacuate the building unless necessary. We found that the Health and Safety testing and servicing has been undertaken as required and staff told us that their Health and Safety is well protected as well as the people who live at the service. We looked at the accident book and saw that all accidents and incidents are documented and relatives are informed. Regulation 37 notices are completed Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 26 where appropriate and sent to the Care Quality Commission. (This is a regulatory process which informs us of any reportable incidents that occur at the service.) Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000059536.V376310.R01.S.doc 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 4 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Version 5.2 Page 28 Nottingham Neurodisability Services Aspley 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. Nottingham Neurodisability Services Aspley DS0000059536.V376310.R01.S.doc Version 5.2 Page 29 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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