Care Home: Orchard House Nursing Home

What the care home does well People have access to information about the service in a format they can understand enabling them to establish the home`s suitability to meet their needs. Needs assessment are undertaken to ensure people`s care and social needs are met when they move in. People`s involvement in their care planning ensures they receive the necessary support in a way they prefer. Detailed care plans ensure staff know how to support people so their best interests are assured. Appropriate management of people`s prescribed medicines ensure people`s wellbeing. People can be assured their dying wishes will be respected. People have access to a variety of social activities so they can live a fulfilled lifestyle. People can be confident their specific needs regarding their religion and culture will be met. Access to a complaints procedure and systems adopted by the home ensures people`s complaints will be listen to and acted on so their rights and protection are assured. Skilled staff members provided in sufficient numbers ensures people`s wellbeing. The availability to equipment and adaptations supports people`s independence and safety. People can be confident that meals provided will reflect their specific dietary needs. People are assured the home will be run in way that supports their rights and ensure their welfare.DS0000068497.V375678.R01.S.docVersion 5.2A visiting healthcare professional said, "The care is OK, I don`t have any issues with the home." "They get poorly people better." A visiting relative told us, "The care is very good." One person who lived there said, "The staff are very good." Another person who used the service told us, "The meals are good." What has improved since the last inspection? What the care home could do better: To ensure a suitable restrictor is fitted to the bathroom window situated on the second floor so people`s safety can be assured. To ensure privacy screening is provided to all windows so people can be confident their privacy will be assured. Consideration should be given to ensure all parts of the home accessible to people are maintained to a good standard to enhance their comfort.DS0000068497.V375678.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Orchard House Nursing Home 16-18 Riley Cresent Wolverhampton West Midlands WV3 7DS Lead Inspector Dawn Evans Key Unannounced Inspection 23rd June 2009 10:00 DS0000068497.V375678.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. DS0000068497.V375678.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). 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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 DS0000068497.V375678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orchard House Nursing Home Address 16-18 Riley Cresent Wolverhampton West Midlands WV3 7DS 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) 01902 653500 01902 334707 First Care Services Ltd Ruth Butler Ms Narinder Anita Kaur Care Home 38 Category(ies) of Dementia (38), Mental disorder, excluding registration, with number learning disability or dementia (38) of places DS0000068497.V375678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia (MD) 38 Dementia (DE) 38 The maximum number of service users who can be accommodated is: 38 Age: Dementia (DE) - age 55 and above. 2. 3. Date of last inspection 3rd July 2007 Brief Description of the Service: Orchard House Nursing Home provides a service for older and young people who have mental health needs or dementia and may need nursing care because of their mental health. The home is located in a residential area and there are a range of community facilities nearby, including shops and pubs. The bus route is within walking distance from the home making access to the Wolverhampton City Centre easy. The property offers 16 shared and four single bedrooms located on three floors. Situated on the ground floor are two lounges, dining room, activity room, kitchen and a range of bathing facilities. Equipment and adaptations are available to support people’s independence and safety, these include, nurse call alarm, hoist, grab rails, passenger lift and ramp access to the garden. Ample off the road car parking is available at the front of the property. DS0000068497.V375678.R01.S.doc Version 5.2 Page 5 Staffing is provided on a 24 hour basis offering the relevant support to people when needed. People have access to range of healthcare services to ensure their healthcare needs are met. Previous inspection reports are available for people to read if they so wish, enabling them to find out about the quality of the service provided and people’s experiences of living there. The fees charged for the service provided at Orchard House is from £448.00p £600.00 per week. DS0000068497.V375678.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 Star. This means the people who use this service experience excellent quality outcomes. This inspection was carried out over one day; the home did not know we were going to visit. The focus of inspections we, the Commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, standards of practice and focuses on aspects of service provision that need further development. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the last key inspection. This included notifications received from the home. These are reports about things that have happened in the home that they have to let us know about by law, and an Annual Quality Assurance Assessment (AQAA). This is a document that provides information about the home and how they think that it meets the needs of people living there. Four people living in the home were ‘case tracked.’ This involves establishing individual’s experiences of living in the care home by meeting them, observing the care they receive, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps we understand the experiences of people who use the service. We looked around some areas of the home. A sample of care, staff and health and safety records were looked at. We spoke to four people who use the service, two care staff, two visiting relatives and one healthcare professional. Their comments have been included in this report. We sent eleven of ‘Have your Say’ surveys people who use the service. We received three of returned surveys and these views have been included in this report. DS0000068497.V375678.R01.S.doc Version 5.2 Page 7 What the service does well: People have access to information about the service in a format they can understand enabling them to establish the home’s suitability to meet their needs. Needs assessment are undertaken to ensure people’s care and social needs are met when they move in. People’s involvement in their care planning ensures they receive the necessary support in a way they prefer. Detailed care plans ensure staff know how to support people so their best interests are assured. Appropriate management of people’s prescribed medicines ensure people’s wellbeing. People can be assured their dying wishes will be respected. People have access to a variety of social activities so they can live a fulfilled lifestyle. People can be confident their specific needs regarding their religion and culture will be met. Access to a complaints procedure and systems adopted by the home ensures people’s complaints will be listen to and acted on so their rights and protection are assured. Skilled staff members provided in sufficient numbers ensures people’s wellbeing. The availability to equipment and adaptations supports people’s independence and safety. People can be confident that meals provided will reflect their specific dietary needs. People are assured the home will be run in way that supports their rights and ensure their welfare. DS0000068497.V375678.R01.S.doc Version 5.2 Page 8 A visiting healthcare professional said, “The care is OK, I don’t have any issues with the home.” “They get poorly people better.” A visiting relative told us, “The care is very good.” One person who lived there said, “The staff are very good.” Another person who used the service told us, “The meals are good.” What has improved since the last inspection? What they could do better: To ensure a suitable restrictor is fitted to the bathroom window situated on the second floor so people’s safety can be assured. To ensure privacy screening is provided to all windows so people can be confident their privacy will be assured. Consideration should be given to ensure all parts of the home accessible to people are maintained to a good standard to enhance their comfort. DS0000068497.V375678.R01.S.doc Version 5.2 Page 9 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. DS0000068497.V375678.R01.S.doc Version 5.2 Page 10 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 DS0000068497.V375678.R01.S.doc Version 5.2 Page 11 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 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. Access to relevant information and the undertaking of assessments before people are admitted to the home ensure their needs will be met. EVIDENCE: The AQAA shows people have access to a Statement of Purpose and Service User Guide. We observed these documents were accessible in the home and provided people with information about the service and facilities offered. The manager said these documents can be made available in various languages, large print and Braille, so people can understand them. The DS0000068497.V375678.R01.S.doc Version 5.2 Page 12 manager told us people have access to this information before they are admitted, enabling them to find out the service’s suitability to meet their assessed care and social needs. The people we spoke to were not able to tell us if they had received this information. However, three out of three surveys received from people who use the service told us they had received information about the home before they moved in. The AQAA told us people have a needs assessment before being admitted. A needs assessment enables the home to establish the person’s care needs and the level of support required to ensure their independence and health. The manager said where possible people or their representative are involved in their assessment. This should ensure people have a choice on how they receive their care. We looked at four care records that contained evidence of the undertaking of these assessments and provided detailed information about people’s physical and mental health needs and told staff how to support the person. The home does not provide intermediate care facilities therefore, this standard was not assessed. DS0000068497.V375678.R01.S.doc Version 5.2 Page 13 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that staff will know how to meet their assessed care needs ensuring their wellbeing. EVIDENCE: Each person had a written care plan. This is an individualised plan that tells staff about people’s care needs and what support is required from staff in order to meet people’s needs. We case tracked four people and looked at their care plan, these provided detailed information. For example, one care plan supplied relevant information about a person’s behaviour that challenged the service and told staff how to DS0000068497.V375678.R01.S.doc Version 5.2 Page 14 manage these behaviours to ensure the person’s welfare. We spoke to two staff members who were aware of this person’s care needs. This person told us they were in good health and said, “The staff are very good.” The home provides palliatives care, this means supporting people at the end of their life and ensuring their last wishes are respected. The care plan told staff about pain management to ensure the person’s comfort and also showed they had access to the local hospice, providing additional professional support to ensure the person’s wellbeing. The care plan also provided staff with information about the care and equipment needed to manage the person’s pressure sores. This person also had access to a Tissue Viability Nurse to monitor wound care and provide staff with professional support. An ‘advance care plan’ provided staff with relevant information on how to ensure the person’s comfort, dignity and privacy during their last stage of life. Two staff members said they were currently undertaking palliative care training. The AQAA states, “The home is actively working towards accreditation for the Gold Standards Framework – Palliative care for service users with dementia or deterioration in physical health.” This training should ensure staff have the skills and knowledge to meet people’s needs at the end of their life. Details of people’s mental health needs, the support required to orientate them with their surroundings and reduce their anxieties were shown in care plans. We also observed these practices taking place. Discussions with staff confirmed their awareness of people’s needs. People can be confident staff will know how to meet their mental health needs. We spoke to a visiting healthcare professional who said, “The care is OK I don’t have any issues with the home, they get poorly people better.” “I feel care plans are detailed and I can find all the information needed and they are always up to date.” One visiting relative said, “The care is very good.” The AQAA states, “Each service user is involved, as far as possible, in the creation, maintenance and review of their care plan.” Although people we spoke to were unable to tell us about their involvement in planning their care. Two care staff told us people were encouraged to take part in their care planning and people’s signature in their care plan provided evidence of this. This should ensure people receive the support and care in a way they prefer. People had access to a range of healthcare services including, dentist, optician, community psychiatric nurse and psychiatric consultants amongst others. DS0000068497.V375678.R01.S.doc Version 5.2 Page 15 Records were maintained of healthcare visits. We also observed staffs prompt action in contacting the emergency service for a person on the day we visited. Access to these relevant healthcare services ensures people’s physical and mental health needs are met. We looked at how the home manages people’s prescribed medicines. The manager said medicines were only given out by a qualified nurse. Staff records showed nurses have regular competency assessments to ensure they have the necessary skills and knowledge to give out medicines safely. We saw that all medicines were securely stored. Medication administration records (MAR). This is a record of people’s medicines; these were signed when medicines were given out. These practices should ensure people receive their medicines as directed by their doctor and also provide an audit trail. Written protocols were also in place for the appropriate use, storage and recording of medicines so staff know how to handle medicines safely and ensure people’s health. A visiting healthcare professional said, “The home has a good philosophy with medication; if the person doesn’t need it then they will take the necessary measures to have them reviewed.” We saw staff respecting people’s right to privacy; they knocked on doors before entering private rooms. People were assisted with their personal care needs within the privacy of their rooms. Bedroom doors were fitted with a security lock and the AQAA showed people were assessed to see whether they were able to have a key to their bedroom door. We also saw that shared rooms were provided with dividing privacy curtains. We observed that some bathrooms and toilets did not have blinds or curtains at the windows. Consideration should be given in providing some screening at these windows to ensure people’s privacy and dignity. The AQAA told us people’s preferred form of address is shown in their care plan. We observed this and heard staff addressing people as they prefer, respecting their choice. DS0000068497.V375678.R01.S.doc Version 5.2 Page 16 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. We have made this judgement using a range of evidence, including a visit to this service. People have access to various social activities and are supported to live a fulfilled lifestyle. EVIDENCE: The daily routine was relaxed with people engaging in pastimes of their choice. The home had an activities coordinator providing four hours of activities per day and was flexible to meet people’s social needs. We saw them getting people involved in activities in the garden. Others chose to watch television, some preferred to be alone with their bedroom. One person told us they had just been out for a walk. Two people who use the service said they had access to leisure services in their local community. The manager said social activities consisted of DS0000068497.V375678.R01.S.doc Version 5.2 Page 17 flowering arranging, food tasting, day trips, outside entertainers, pub lunches, model making, jewellery and clothes parties amongst others. One person said, “I am happy here there is always something going on.” Consideration was also given regarding people’s disability, race and religion. For example, people who have a visual impairment were able to attend ‘Beacon Centre for the blind,’ if they wish. One person attended an ‘Asian Well Man Centre.’ One person said, “I had a bible reading this morning.” “I really enjoyed it.” A visiting healthcare professional said, “I see the church come in, family visiting, people going out into the community.” “People have a choice regarding their lifestyle.” People have access to various newspapers and magazines to reflect their culture and social interests, this included English and Punjabi newspapers, and classic magazines amongst others. This enable people to continue to be involved their interests. Staff said people are able to maintain contact with their family and friends. One person told us their wife visited on a regular basis. We observed family and friends visiting the home. Two visiting relatives told us they were able to visit at anytime and staff always made them welcome. People are therefore, assured they can maintain contact with people important to them. The home’s menu offered various meals to reflect people’s nutritional needs. There was also a separate menu for vegetarians and one to shows people’s cultural dietary needs. A menu board was displayed in the dining room showing meals available for the day. One person said, “The meals are good, if I want anything different I just knock on the kitchen door and ask the cook.” “I get my Jamaican food and they cook it well.” Another person said, “The meals are alright, we’ve got pizza for tea.” We observed the evening meal to be appetising. DS0000068497.V375678.R01.S.doc Version 5.2 Page 18 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. We have made this judgement using a range of evidence, including a visit to this service. People are assured their complaints will be listen to and acted on ensuring their rights and protection. EVIDENCE: The AQAA told us the home have a clear effective complaints procedure in place. We saw this procedure was accessible to people. Three out of three surveys received from people who use the service told us they know how to make a complaint. One person said, “You see that lady (manager) there, if you have any problems just go to her, she sorts everything out.” The AQAA showed the home had received 20 complaints since the last inspection visit. The manager said all complaints no matter how little are recorded. We saw records were maintained of complaints and showed what action had been taken to resolve the problem. People can be assured their concerns will be listened to and their rights respected. DS0000068497.V375678.R01.S.doc Version 5.2 Page 19 The home had three safeguarding referrals. This is where there has been an allegation of abuse or where practices may compromise people’s health and safety. One referral related to an incident that occurred before the person was admitted to the home. The other two referrals related to one of the same incident and were investigated by Social Services. There was no evidence of any poor practices within the home. Discussions with the manager and records we look at showed the home had taken the necessary action to report these incidents to the appropriate agencies to safeguard people within their care. We spoke to two staff members who said they had received safeguarding training. This training enables staff to recognise various forms of abuse. Staff told us if they had any concerns about potential abuse to people they would report it to the manager or us. People can be assured that staff will have the skills and knowledge to protect them from abuse. We have not received any concerns or complaints about the service. DS0000068497.V375678.R01.S.doc Version 5.2 Page 20 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. We have made this judgement using a range of evidence, including a visit to this service. The layout and design of the home was suitable to meet people’s assessed needs but insufficient maintenance of the building does not provide a homely environment. EVIDENCE: DS0000068497.V375678.R01.S.doc Version 5.2 Page 21 The three storey detached property provides four single and 16 shared bedroom located on all floors. Bedrooms are not equipped with en suite but bathrooms and toilets are nearby. The window located in a bathroom on the second floor did not have an appropriate restrictor to ensure people cannot fall through it. Shared bedrooms were very compact and may impinge on people’s privacy. However, one person who live at the home said, “I share bedroom with X, I don’t mind sharing and I’m happy with my room.” The property consists of a number communal rooms located on the ground floor, these included lounges, dining room and an activity room. Equipment and adaptations were also in place to support people’s independence and safety, such as passenger lifts, grab rails, ramp access to the garden. The garden area had recently been developed enabling wheelchair access. Waist height flower beds allowed people with a physical disability to be involved in gardening projects. The interior of the property and some furnishings were old and worn. For example, the wall paper in one bedroom was coming away from the wall. Walls and woodwork needed painting. One person did not have a view from their bedroom window and had very little natural light coming in. The manager acknowledged the home was in needed of refurbishment. The AQAA showed improvement could be made with on going decorating of all areas of the home and the replacement of furniture’s in bedrooms. The AQAA also showed some bedrooms have recently had new carpet, the dining room had been decorated and additional dining tables have been added. All beds and mattresses had been replaced. This should provide a more stimulating and comfortable area for people to live. The AQAA told us the home employs two cleaners to maintain the cleanliness of the home. Two out of three surveys from people who use the service told us the home is usually fresh and clean. We observed that the cleanliness of the home was maintained to good standard so people’s comfort and safety are assured. DS0000068497.V375678.R01.S.doc Version 5.2 Page 22 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Skilled staff provided in sufficient numbers ensure people are supported so their wellbeing and best interests are assured. EVIDENCE: The home is able to offer a service to 38 people; the manager told us 35 people were currently living there. Two staff members told us sufficient staffing was provided to meet people’s needs. Discussions with the manager and staff working rotas showed one registered nurse and four care staff were provided during the day, having one registered nurse and two carers at nights. The home provided domiciliary staff so care staff could focus entirely of people’s care and social needs. DS0000068497.V375678.R01.S.doc Version 5.2 Page 23 Rotas also showed additional staffing was provided during peak times of the day. For example at mealtimes or to assist people to attend planned appointments. An activity coordinator provided social activities for four hours each day. The manager was confident that sufficient staff was provided to support people and we observed staff being very attentive to people’s needs and were always nearby to assist them when necessary. One visiting relative said, “There always seem to be enough staff on duty.” “Staff are always around the home” The manager said 15 out of 21 care staff have obtained the National Vocational Qualification level 2 or above. Two care staff spoken to told us they had completed this training. This should ensure staff have the skills and knowledge to meet people’s care needs effectively. The home was committed to staff training and development. Discussions with staff and the training matrix showed they had received the following training: Fire Safety, First Aid, Moving and Handling, Food Hygiene, Health and Safety, Infection Control, Dementia Awareness, Mental Health Awareness, Care of the Dying, Mental Capacity Act, amongst others. If the skills obtained from these training are put into practice, people’s wellbeing and best interests can be assured. The manager told us that all new staff have the appropriate safety checks before working in the home. We looked at three staff personnel files, which showed safety checks were undertaken. These included a Protection of Vulnerable Adults (PoVA 1st) clearance, Criminal Record Bureau (CRB) and two written references. We spoke to two care staff who confirmed they had these safety checks before they started to work in the home. These checks should ensure staff’s suitability to work with vulnerable people. DS0000068497.V375678.R01.S.doc Version 5.2 Page 24 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. We have made this judgement using a range of evidence, including a visit to this service. People can be assured the home will be managed in a way that supports their health and best interests. EVIDENCE: The home has two registered manager, one is a Registered Mental Health Nurse and both have obtained the Registered Managers Award. The AQAA DS0000068497.V375678.R01.S.doc Version 5.2 Page 25 states, “Each has different skills and we feel that we compliment each other with our individual knowledge and experience.” The home had various systems to monitor the quality of service provided to people. This included a quality assurance survey, which was sent to people who there. We saw the outcome of these surveys displayed in the home. It showed 68 of people were happy with the service, 18 mainly satisfied, 9 very satisfied, 3 excellent and 2 no comment. This process supports people to be involved in the running of the home and tells the management what areas need to improved. The home also undertook regular weekly audits on medication systems and practices and infection control. The manager told us they had received a bronze award from the Health Protection Unit. People can therefore, be assured practices will ensure their health and safety. Some people required the use of bed guards; risk and maintenance assessments were in place for the safe use of this equipment. Records showed people were also assessed on a regular basis to find out if they still required the use of bed guards. These practices ensure people’s best interests. A monthly audit of accidents and incidents were also undertaken to find out if there is pattern of incident. This enabled them to put the appropriate control measure in place to reduce or eliminate further risks and so ensure people’s safety. Regular meetings were also undertaken with people who live there, enabling them to have a say how they receive their care. The manager said some people do not have the mental capacity to manage their financial affairs; this was done by either the person’s family or Social Services. The home does not hold any money for people but fund people’s expenses from the home’s budget. Records of expenditures and receipts were maintained, which is then sent to Social Services who then reimburse the homes funds. The manager was confident that these practices reduced the risk of financial abuse. We looked at systems in place that supported people’s health and safety. A fire risk assessment was in place so staff know who to ensure people’s safety in the event of a fire. Electrical appliances were checked each year to ensure they are safe to use. The home public liability insurance was up to date. DS0000068497.V375678.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 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 3 DS0000068497.V375678.R01.S.doc Version 5.2 Page 27 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 The window located in the bathroom situated on the second floor did not have an appropriate restrictor. Necessary measures must be taken to ensure the security of this window so people’s safety can be assured. Timescale for action 16/07/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP10 Good Practice Recommendations To ensure all parts of the home accessible to people are maintained to a reasonable standard so people’s comfort can be assured. To ensure privacy screening is provided in all private rooms so people’s right to privacy can be assured. DS0000068497.V375678.R01.S.doc Version 5.2 Page 28 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT 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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