Care Home: Old Racecourse Road, 6a

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What the care home does well Residents are supported to live independent and safe lives in a way that they choose. Residents health and personal care needs are well recorded and they are well supported and monitored to ensure they stay well. Staff treat residents with respect and their privacy and dignity is observed all the time. The residents are given opportunities to take part in the things they like to do both at home and in the local community. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Available at the home are written and pictorial complaints procedures and people are confident about complaining if they need to. Staff have been properly recruited to make sure they are right for the job. The manager runs the home well and in the best interests of the residents. What has improved since the last inspection? Two of the residents bedrooms have been redecorated, a new dining set, cooker and microwave have been bought for the kitchen and Sky TV has been installed at the home. Staff records are now kept at the home and show that they were properly recruited. What the care home could do better: Improvements as described in the main body of this report should be carried out to the home to ensure residents dignity and comfort. All staff who work at the home must be provided with protection of vulnerable adults (POVA) training on a more regular basis so that they have up to date information about how to recognise and deal with incidents of abuse. Staff that work at the home must be provided with mental health awareness training to ensure they can fully meet the needs of the residents. Key inspection report CARE HOME ADULTS 18-65 Old Racecourse Road, 6a 6a Old Racecourse Road Maghull Liverpool Merseyside L31 8AN Lead Inspector Janet Marshall Key Unannounced Inspection 29th September 2009 09:30 Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 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. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 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 Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Old Racecourse Road, 6a Address 6a Old Racecourse Road Maghull Liverpool Merseyside L31 8AN 0151 531 6154 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) Expect Limited Manager post vacant Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 3 Date of last inspection 6th September 2007 Brief Description of the Service: 6A Old Racecourse Road is registered as a care home for three people with a learning disability. There are currently three women in residence. The service provider for the home is Expect Ltd. This organisation is in the voluntary sector and is a registered charity. The registered Landlord for the property is Liverpool Housing Trust. The property is a five bed roomed dormer bungalow. The home is located in a residential area in Maghull, Merseyside. It is in keeping with other properties in the area and is indistinguishable as a residential care home. The home is located approximately one mile from local shops and is a fifteen minute walk from the nearest train station. Fees for the home vary depending on the needs of the residents. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 star. This means the people living at the home experience good outcomes. This was a key inspection. We consider 22 out of the 43 National Minimum Standards for this type of service, Care Homes for Adults (18-65) as the key standards, which have to be inspected during a key inspection. The key standards are highlighted in bold in the different outcome sections of this report. A key inspection is a planned inspection, the report has been put together using information gathered in a number of different ways, which helps us decide the overall rating of the service. We keep all information we receive about the home in a file, we looked at all the information we have received since the last inspection. We sent out a form to the home called an Annual Quality Assurance Assessment (AQAA). The AQAA has to be filled in and returned to us by a set date usually before the site visit takes place. The AQAA was filled in by the manager and returned to us on time, it provided us with all the information we asked for about the service. We carried out an unannounced visit to the home, this is when we visit the home with out any body knowing and is called the site visit. All three residents were at the home when the site visit started. The residents, the manager and support staff that were on duty all helped with the inspection. Also during the site visit a selection of records and certificates, which have to be kept in the home by law were looked at and checked to make sure they were up to date and accurate. Two residents were case tracked. This is a process we use to find out whether the people that live at the home are receiving good quality care that meets their individual needs. It is done by talking to people, looking at results of surveys and reading the records of a sample of people that live at the home to give us a good idea of what it is like for them. Before the site visit took place we sent out Have Your Say surveys to people asking them about what it is like to live and work there. No surveys were returned at the time of writing the report. What the service does well: Residents are supported to live independent and safe lives in a way that they choose. Residents health and personal care needs are well recorded and they are well supported and monitored to ensure they stay well. Staff treat residents with respect and their privacy and dignity is observed all the time. The residents are given opportunities to take part in the things they like to do both at home and in the local community. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 6 Available at the home are written and pictorial complaints procedures and people are confident about complaining if they need to. Staff have been properly recruited to make sure they are right for the job. The manager runs the home well and in the best interests of the residents. 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. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 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 Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 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): 2. 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. Procedures followed for assessing and admitting a new resident to the home ensure it is the right place for them to live. EVIDENCE: One new resident has been admitted to the home since the last key inspection. The AQAA told us about the different types of need assessments, which are routinely carried out before a person is admitted to the home. They include assessments carried out by a manager of the service using the companies standard assessment forms and assessments carried out by other qualified people, such as social workers and nurses. Assessments cover things about the persons life such as communication, mobility, health and personal care, social interaction, behaviour and relationships. Once completed the assessments are used to decide if the persons needs can be met at the home and also so that they can be sure it is the right place for them to live. The manager said residents and their family/carers are fully involved in the assessment process. Residents care needs are assessed on a regular basis to make sure that they can continue to be met at the home. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 9 Pre-admission assessments for the new resident were looked at as part of the case tracking process this showed that the persons needs were properly assessed before a decision about them moving into the home was made. The new resident said, they were invited to look around the home, meet with other residents and staff and viewed their bedroom before they decided to move in. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 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): 6, 7 & 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have all the information they need to support residents needs and to enable them to make every choices and decisions. EVIDENCE: Each of the residents had a care file. Files for two residents were looked at in detail as part of the case tracking process. The files were kept safely at the home. At the beginning of each residents file was a personal profile titled ‘Pen Picture’ this was a short story telling the reader important things about the resident such as, were they were born, were they used to live, family members and things, which are important to them. One resident confirmed that she wrote her own profile. Care files also included an Essential Lifestyle Plan, which is a person centred type of care plan. The plans, which were looked at provided staff with Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 11 important information about how to support residents to live the kind of live they choose whilst also providing them with the care and support they need. There was written evidence to show that plans are reviewed each month with the involvement of the resident and other important people in their lives. Residents that live at the home communicate in a number of different ways. Some use spoken words, those with limited use of words communicate in other ways such as by using pictures, symbols, facial expressions and gestures. On the day of the inspection visit staff were seen communicating with residents in their preferred way, information about this was recorded in their care plans. A resident spoken with during the site visit said, “Yes, I always make my own decisions and choices, I choose where I want to go and what I want to do. I decide what I wear each day. The staff give me advice when I need it”. Residents care plans included information about how they communicate. There was also information about the choices and decisions they can make themselves and any help they need with others. Care files, which were looked at showed that risk had been assessed before the resident moved into the home and any risk or hazard identified has been risk assessed. Risk assessments, which were in place, detailed the action which needs to be taken so that residents can safely take part in a task or activity. They were also in place to help staff manage certain behaviours in a positive way. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 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: 12, 13, 15, 16 & 17. 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. Residents are encouraged and supported to live active and healthy lifestyles. EVIDENCE: The AQAA told us that residents are supported to take part in activities of their choice and they are part of the local community. Care files that were looked at included information about the residents preferred interests and hobbies and they had an activity timetable, which has been put together around their preferences. The manager said were possible residents are fully involved in putting together their timetable and they are reviewed and updated on a regular basis. One resident spoken with said, “I get out and about a lot”. The resident talked about their particular interests and hobbies, which included shopping for both personal items and groceries Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 13 for the home, cooking, baking and knitting. They said, “I really enjoy cooking my own meals and cooking for others and I love to bake”. Other residents rely on staff to help them with their interests and hobbies at home and in the community. Case tracking showed that those residents are supported to do the things they enjoy both at home and in the community. They have regularly gone out to shops, cafes, pubs and restaurants as well as going on holiday. Assessments, activity programmes, daily records and discussions with staff were looked at as part of the case tracking. The manager said residents are encouraged to help with the up keep of the home including cleaning, laundry and cooking. A resident said,” Yes I help with cleaning, I clean my own room and the bathroom and help with the dishes”. A resident said they have their own front door key, which they use all the time. The AQAA told us that residents are encouraged to help put together menu plans. Written menus, which were seen, included a variety of meals which were well balanced and nutritious. The manager was advised to also use pictures, photographs and symbols to help those residents who have difficulties reading. Residents are encouraged to eat their meals at the family sized dining table which is in the kitchen/diner, although if they want they can eat their meals in the lounge or in their own rooms. A resident said, they shop for food each day and get to choose the food they like. The resident also said they help to cook their meals and can have a snack during the day if they want. Information about the types of food, which residents like and dislike, was recorded in their care file. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 14 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are treated with respect and their personal and healthcare needs are well recorded and appropriately supported. EVIDENCE: Care plans provided information about residents health and personal care needs and how they are to be met. If residents need to attend healthcare appointments staff support them with this. Details of appointments such as with doctors, opticians and dentists were well recorded. Some residents are visited at home by health care professionals for specialists conditions, records of the visits were also available in good detail. Care plans also included information about residents preferred routines around personal care. Staff spoken with had a good understanding of the residents personal and healthcare needs and gave examples about how they respect their privacy and dignity. Examples staff gave included, “I always make sure doors are closed when helping a resident to bath and when helping them with Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 15 other personal care”. “I always knock on the residents door before entering their bedroom”. “I talk to residents and explain what I am helping them with”. During this inspection visit all medication and medication administration records were examined. Medication and records were stored securley. Discussion with staff and examination of records showed that staff are provided with medication awareness training. One member of staff that was on duty said she does not give out medication because she has not yet completed the training and is booked on a course in the near future. A policy for the safe handling and administration of medication was availble at the home. The manager showed a good awareness of the homes medication polices and procedures. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 16 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and staff have all the information they need to make a complaint if they need to and they are confident about complaining. Some staff who work at the home have not been provided with up to date POVA training, which puts the residents at risk. EVIDENCE: The AQAA told us that there have been no complaints made at the home in the last year. The Commission has received no complaints regarding the service since the last inspection. There were written and pictorial complaints procedures available at the home. There was also a complaints book to record any complaints made directly to the home. The Service User Guide and the homes Statement of Purpose also included a summary of the homes complaints procedure. One resident spoken with said they know about the homes complaints procedure and would complain if they were unhappy about something. The manager said that resident’s family/representatives have also been given a copy of the complaints procedure. A member of staff spoken with said that they knew about the complaints procedure and would be confident about raising any concerns or complaints if they needed to. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 17 The AQAA did not tell us anything about POVA procedures so this was looked at in detail during the site visit. A Protection of Vulnerable Adults (POVA) procedure was available at the home. The manager said staff have received or are planning to attend POVA training, she said the topic is covered in the induction programme for new staff so all staff are aware of the basic principles of POVA. Instead of POVA some people say abuse training or safeguarding. Two members of staff who were spoken with during the site visit were asked what they would do if they saw or thought a resident was being abused, they said they would report any incident of abuse with out hesitation. Staff training records, which were looked at showed they have not undertaken POVA training for at least 2 years. All staff who work at the home must be provided with POVA training on a more regular basis so that they have up to date information about how to recognise and deal with incidents of abuse. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 18 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 & 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Procedures followed at the home ensure it is safe and hygienic but the comfort and dignity of residents is undermined by parts of it, which are in need of improving. EVIDENCE: The home is a dormer style bungalow located in a popular residential road in Maghull Merseyside. There is a driveway at the front of the home, which provides off road parking spaces for at least two cars. At the back of the home is a good sized enclosed garden with a lawn, planted out borders and a patio area. The AQAA told us about the improvements, which have been carried out to the environment since the last inspection, they include the redecoration of two residents bedrooms, a new dining set for the kitchen, a new cooker and microwave and installation of sky TV. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 19 The manager said other parts of the home are due to be decorated including the hall stairs and landing areas. The AQAA told us about the plans to make further improvements to the home in the next year. They include the replacement of all inside doors, which were in poor condition, the replacement of the carpet and suite in the living room which were damaged in parts and the redecoration of the kitchen, which was worn and dull in places. On the day of the inspection visit residents were seen moving freely around the home, equipment was available for those that needed it to help them get around and staff were seen assisting with this. One resident gave a tour of their bedroom. The room was spacious and nicely personalised with the residents own possessions but the decoration and some fittings were tatty. Wall paper was peeling off on some of the walls and the curtain rail was broken. The room should be decorated and repairs should be carried out to ensure the dignity and comfort of the resident. The resident said their TV was not working because there was a fault with the aerial following recent work carried out in relation to the forthcoming digital changeover. When asked if they had reported the fault they said they had. This was discussed with the manager who produced records to show that they had requested for the aerial to be repaired. The manager was advised to pursue the matter as the resident particularly enjoys sitting in their room watching TV in the evenings. The upstairs bathroom suite is very old. The main suite is brown but the toilet seat, which has been replaced, was pink and the cistern lid also replaced was white. The bathroom suite should be replaced to ensure the comfort and dignity of the residents. At the time of the site visit both the inside and outside of the home was clean and tidy and there were no hazards found. The AQAA showed that the required policies and procedures for control of infection and cleaning routines are in place at the home. It also showed that soiled laundry is washed appropriately and clinical waste is disposed of in the correct way. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are properly recruited but some need to attend training to update their knowledge and skills, which are required to meet the needs of the residents. EVIDENCE: The AQAA showed that strict staff recruitment procedures are in place and the company is an equal opportunities employer that ensures issues of equality and diversity are thoroughly addressed during the interview process. The AQAA showed that satisfactory recruitment checks have been carried out for all staff that work at the home. Examination of the staffing rota and details provided in the AQAA showed that there are eight permanent staff that work at the home and the team is made up of people of various age, and ethnicity. The manager said that there is a sleep in member of staff on duty each night and at least two members of staff on duty throughout the day and evening. Staffing rotas, which were looked at showed the right amount of staff on duty at all times. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 21 Discussion with staff, information provided in the AQAA and records seen at the home showed that staff have completed a range of appropriate training and training has been planned for the future. Training courses are relevant to the care and support of the residents and the running of the home. For example first aid, health and safety, protection of vulnerable adults (POVA) and fire awareness. The AQAA showed most staff are working towards a National Vocational Qualification (NVQ) Level 2 or above in care. Discussion with people showed that some staff have not been provided with the training they need to be able to understand and manage certain mental health conditions that some residents have. Discussion with resident this was discussed with the manager, who said she would ensure that all staff are provided with the right training. Staff that work at the home must be provided with all the training they need to ensure they can meet the needs of the residents. Two new staff have started work since the last inspection. Training records for one new member of staff, which were looked at during the site visit showed they received induction training when they started work at the home. The AQAA told us that all new staff are provided with induction training and they have a development programme, which meets the National Minimum Standards for this type of service. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 22 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, 39 & 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed to the benefit of the residents and staff. EVIDENCE: The manager of the home Christine Devereux has worked within the companies residential services for a number of years both as a support worker and a manager, all in all she has 20 years experience of working in care. We were told in the AQAA that the manager has obtained a number of qualifications relevant to her role including an NVQ level 4 in Care and the Registered Managers Award. Other training completed by the manager, which we were told about includes: risk management, staff supervision and appraisal Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 23 and management foundation. The manager said she feels capable and competent within her role as manager. Christine has applied to us the Care Quality Commission for approval as the registered manager of the home, our records show that her application is being processed. Staff and residents spoken with were complimentary of the manager and the way she runs the home, they made the following comments to support this, The manager is very good with the residents, The manager is supportive . “The manager has is good at her job”. “She listens and is very approachable”. ` The AQAA told us that there are systems in place for reviewing and improving the quality of care provided at the home. This was evidenced by records which were seen during the site visit. Residents care plans, medication, the environment and residents finances are some of the areas, which are monitored and recorded on a regular basis. A representative of the organisation also visits the home each month to check that the home is running in the best interests of the residents. They write a report following the visit detailing their findings, copies of the reports are kept at the home. Also as part of the homes quality monitoring systems residents and their families/representatives are invited to complete questionnaires to gather their views and opinions about all different aspects of the home for example, the staff, the food, the environment and their lifestyle. The results of the questionnaires are used to help make improvements to the service and plan for the future. The AQAA told us that the home has available all the health and safety policies and procedures, which they have to have by law to ensure the health safety and welfare of the residents and staff. It also told us that the required checks have been carried out on the gas and electricity systems and equipment used at the home to make sure they are safe and in good working order. Discussions with staff during the inspection visit and information provided in the AQAA showed that staff have recently received training in subjects of health and safety such as fire awareness, lifting and handling and first aid. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 24 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 2 ENVIRONMENT Standard No Score 24 2 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 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Version 5.3 Page 25 Old Racecourse Road, 6a DS0000005426.V378862.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. 1. Standard YA23 Regulation 13 Requirement All staff who work at the home must be provided with POVA training on a more regular basis so that they have up to date information about how to recognise and deal with incidents of abuse. Staff that work at the home must be provided with all the training they need to ensure they can meet the needs of the residents. Timescale for action 29/01/10 2. YA35 18 29/03/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations Decoration and furniture in the home should be of a better standard to ensure the comfort and dignity of the residents. Old Racecourse Road, 6a DS0000005426.V378862.R01.S.doc Version 5.3 Page 26 Care Quality Commission North West 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). 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. 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