Care Home: Positive Community Care

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What the care home does well The home provides people with the opportunity to develop independent skills so that where possible people can move on to more independent living accommodation. The staff team are committed to working in the interests of the people living in the home. Links are made with the local community and with mental health resources.Positive Community CareDS0000073029.V374971.R01.S.docVersion 5.2 What has improved since the last inspection? This is deemed the home`s first inspection under the new Limited Company and therefore the previous inspection report carried out in 2007 is not used or considered in this report. What the care home could do better: The home must have robust risk assessments in place for people who are able to manage their own medication and for people who do not respond to the fire drills. Medication must be administered as prescribed and checks and audits need to be detailed to ensure any errors are quickly noted and sorted out. Attention must be paid to areas of the home that need refurbishing, such as flooring in people`s bedrooms. The home must have sufficient numbers of staff working in the home to ensure staff are not working long hours in the home and/or in the supported living schemes. The rota must be reviewed to ensure there are enough staff working and supporting people. The staff team need to have ongoing training on relevant subjects, such as Mental Health issues and topics relevant to supporting people with specific needs. Key inspection report CARE HOME ADULTS 18-65 Positive Community Care 170/174 Pettshill Northolt Middlesex UB5 4NW Lead Inspector Sarah Middleton Unannounced Inspection 30th April 2009 09:40 Positive Community Care DS0000073029.V374971.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. Positive Community Care DS0000073029.V374971.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 Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Positive Community Care Address 170/174 Pettshill Northolt Middlesex UB5 4NW 020 8621 1724 020 8248 8496 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) Positive Community Care Ltd Mr Leisel Alian Vaiphei Suantak Care Home 9 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0), of places Physical disability (0) Positive Community Care DS0000073029.V374971.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 only - Code OP 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 - Code MD Learning disability - Code LD 2. Physical disability - Code PD The maximum number of service users who can be accommodated is: 9 26/11/07, note this is the date when last inspected as individual providers. Date of last inspection Brief Description of the Service: Positive Community Care (PCC) is a care home for nine adults with mental health needs and/or a learning disability. The overall aim of the service is to support people in maintaining and developing their independence and integrating into the community as part of a rehabilitation process, where applicable. Levels of support are defined through individual assessments of need. The home was established in 1997 and initially was two small homes operating side by side, which were later combined into one. A third house (166 Petts Hill which is next to 170) is operated by PCC as a supported living scheme (SLS). The care home’s bedrooms are all singles. Three bedrooms are en-suite. Two bedrooms have been created within the loft space. The home has adequate communal areas including a conservatory and large rear garden. The home is in a residential area, next to a convenience store/petrol station, and is on a bus route. The staff team comprises of a Registered Manager, Deputy Manager, senior support worker and support workers. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 5 Since the last inspection in 2007 the individual providers/owners changed to a limited company. The people involved in managing the business are the same but the change in becoming a limited company has meant that the previous report and findings were not used at this inspection. Therefore this inspection is seen as the homes first under the new company. Fees range from £500- £1,000 per person per week, the fees are based on the level of support each person needs in the home. Positive Community Care DS0000073029.V374971.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 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit carried out on the 30th April 2009 from 9.40am-6pm. Before the visit we looked at: Information we had received since the last visit on the 26th November 2007; The Annual Quality Assurance Assessment (known as the AQAA). The AQAA gives us evidence to support what the home says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are. During this visit we: Talked with the people who live in the home, staff and the Manager. The Registered Manager will be referred to in this report as the Manager. Looked at information about the people living in the home and how well their needs are identified and met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make it was clean, safe and comfortable; Checked what improvements had been made since the last visit. We told the Manager what we found at this visit. What the service does well: The home provides people with the opportunity to develop independent skills so that where possible people can move on to more independent living accommodation. The staff team are committed to working in the interests of the people living in the home. Links are made with the local community and with mental health resources. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 7 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. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed. 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 assessed before they move into the home. EVIDENCE: We discussed with the Manager, the two most recent people who had moved into the home. There were no pre-admission assessments completed by the Manager in either file. The Manager explained that he had completed an assessment for one person but could not locate it at the time of the inspection. However we did see information and assessments from the referrers. This provided some idea of the person’s individual needs. We spoke with the Manager about the importance in completing the pre-admission assessments so that the Manager and staff team have a clear idea of the person’s abilities and needs. The Manager confirmed that people who are considering moving into the home are encouraged to visit and stay over at the home so that they can meet staff and the other people living in the home. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 10 We discussed with the Manager the preferences a new person might have if they needed support with personal care tasks. Some people might prefer a male or female member of staff when needing help with personal tasks. This should be assessed at the assessment stage, recorded and reviewed on an ongoing basis. We were satisfied there was enough information about each person on their files. However there was room for improvement in the completion of detailed pre-admission assessments and this should be addressed for future new people. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 & 9 were assessed. 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. Overall the needs of the people living in the home were assessed and were being met. People are supported to make decisions about their lives. Detailed risk assessments need to be in place in order to fully support the people living in the home. EVIDENCE: We viewed the information on two people who live in the home. Those people asked said they were aware of what was written about them and could be involved with the completion of their care plans. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 12 One file viewed had clear information about the person, what their needs were and how these were to be met. Short and long term goals had been recorded along with how to support the person. Overall the health and social care needs of each person had been noted. Each month the person meets with their allocated keyworker and this is time when the member of staff and the person can look at any issues or changes in the person’s identified needs. We looked at a sample of daily records. These were now a checklist with staff recording what the person did each day and commenting on anything significant. People said they were able to make decisions about their lives. The Manager explained that some people go out independent of staff, whilst some people need support from staff for their own safety. Where possible, people are encouraged to manage their own finances. We viewed risk assessments on the two files. These outlined the assessed and known risks the person either represented to others or to themselves. Monthly room checks are carried out on each room and records were seen of these checks. The Manager agreed to review what is checked so that it covers all potential areas needing to be looked at. We noted when assessing Standard 20 and looked at medication, that one person self medicates. However there was no evidence that staff had considered the risks involved in someone taking on this responsibility. We consider it to be necessary to complete a detailed risk assessment for any important decision the home takes when supporting a person to be more independent. A requirement was made for this to be addressed. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: Standards 12, 13, 15, 16 & 17 were assessed. 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 to take part in activities both in the community and in the home. People are encouraged to maintain social relationships. The people living in the home have a well balanced diet, with a variety of meals on offer. EVIDENCE: The people living in the home take part in a range of activities. The self assessment the Manager had completed recoded that a variety of activities are offered on a weekly basis. Staff were aware of the need to motivate and encourage some people to take part in tasks both in and outside of the home. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 14 Those people asked said they took part in the groups run in the home, such as discussion groups or arts and crafts. We were informed that some people go out to visit friends or attend the local college. Various forms of transport are used, such as tubes, buses and taxis. Day trips are organised and a holiday had been arranged for five of the people living in the home. Local support groups and evening social groups are being accessed for those people interested. The self assessment the Manager had completed recorded that the home has a football team, along with the local supported living scheme, where people can exercise and meet others. One person spoken with spoke positively about this activity. Those staff asked confirmed that people receive support and time with staff on a one to one basis; this is usually during the meetings to see how the person is doing each month with their keyworker or when they need to go shopping for personal items. Both staff and people living in the home informed us that contact with friends and family is encouraged. People are able to see who they want to either in the home or visiting them in the community. There is a public payphone for people to use. Those people asked told us that they can and do lock their bedrooms, so that their property is safe and to ensure they have privacy. One member of staff confirmed that they always knock on the bedroom door before entering a person’s room. We were informed that people receive their own personal mail. We viewed a sample of menus and saw that overall a variety of choices are available for people, including catering for special diets, such as, vegetarian diets. Most people said the staff team cook the meals, but where possible people living in the home are encouraged to help out at mealtimes. To ensure everyone living and working in the home are safe, knives are kept locked away. Positive Community Care DS0000073029.V374971.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): Standards 18, 19 & 20 were assessed. 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. If needed, people receive personal support in a dignified and professional way. People’s health needs are recorded and were being met. Shortfalls and errors in the medication systems could place people at risk. EVIDENCE: The majority of people living in the home carry out their personal care independently. We were informed that two people need support from staff to ensure they maintain their personal hygiene. Where necessary staff are available to encourage and prompt people to take care of their appearance. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 16 The people living in the home have access to health professionals, such as GP, dentist and optician. Medical appointments are noted on a separate form that was seen. This is good practice as this can easily monitor the health needs of the people living in the home and show if there is a deterioration or change in the person’s health needs. We viewed a sample of medication with the Manager. We were informed that staff receive training on medication and new staff spend time observing experienced staff handling and administering medication. We checked two people’s medication. This was carried out by counting all their prescribed medication and checking this against the Medication Administration Records, (known as the MARS records). All the counts for one person were correct, although we could not count one medication, as the quantity had not been recorded on the MARS record. The second person’s medication was all correct, apart from one medication where we both counted and checked and found there was 31 tablets when there should have only been 22. The Manager could not explain what had occurred. Regular counts and checks are carried out and we saw evidence of this. However this particular medication had not been counted by the member of staff during a recent audit. Staff must only sign for medication that is administered and regular through checks and counts need to take place in order to identify and rectify any errors. This must be investigated by the Manager to ensure the medication systems are robust and protect the people living in the home. Two people currently self medicate. The Manager explained that they are given their medication a week at a time and it is checked and counted during the month. As stated in Standard nine, detailed risk assessments need to be in place when enabling a person to self medicate. Positive Community Care DS0000073029.V374971.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): Standards 22 & 23 were assessed. 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’s views are listened to and acted on. Systems are in place to protect people from abuse. EVIDENCE: The home has a complaints procedure and those people asked said they would talk to a member of staff if they had any concerns. We were informed there had been no complaints made to the Manager. We recommended that the Manager develops a complaints record, so that if a complaint was made there would then be a running record of the number and nature of the complaints along with any action taken. Confidential information would need to be kept locked away, but the record could show clearly how the home manages concerns and complaints. Staff receive training on safeguarding adults. We advised the Manager to obtain the “No Secrets” Department of Health’s guidelines when it has been updated and published. The Manager had obtained a copy of the Local Authority’s Deprivation of Liberty Safeguards. The Manager is aware of the Mental Capacity Act and the potential impact this legislation could have on the home. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 18 The Manager needs to ensure that if any person living in the home comes under these guidelines and legislation then he should consult with the relevant Placing Authority. We counted, with the Manager, two people’s personal money. These were correct at the time of the inspection. People are supported to manage their money, either by the home looking after it or if possible, the person is encouraged to collect their own money keep it to spend on whatever they wish. The Manager informed us that people are assisted to budget their money if they need to develop this daily living skill. Positive Community Care DS0000073029.V374971.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): Standards 24 & 30 were assessed. 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. Overall the home is comfortable, safe and clean. EVIDENCE: We carried out a tour of the home and overall it is well maintained. Areas had been improved and are ongoing. Bedroom five had laminate flooring that was chipped and in need of replacing. Areas needing attention must be identified and addressed as soon as possible. This room will be looked at during the next inspection visit. The staff team along with the people who live in the home keep the home clean and tidy. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 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): Standards 32, 33, 34 & 35 were assessed. 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. People are supported by a competent staff team. To ensure people are supported by an effective staff team, the rota needs to be amended and sufficient numbers of staff need to be working at any one time. There are recruitment checks carried out to protect the health and welfare of the people living in the home. For the benefit of staff and the people living in the home the training programme should cover a wide range of subjects. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 21 EVIDENCE: The staff team have worked together for a while and there is a Deputy Manager working along with staff and supporting the Manager. We were informed that three members of staff have NVQ level 2, one is a qualified nurse and another is currently studying for an NVQ. We viewed the rota currently in place. We were told that late in 2008 changes were made to the hours the staff team worked and that there was no longer a shift where staff slept in the home, but now there was a member of staff awake throughout the night. Existing staff that had been working during the day and night were now on the rota to work the waking nights. On some shifts we noted that staff had worked a late shift and they then worked straight into the night and were expected to remain awake. We also noted some people starting work at 6pm, worked throughout the night and into the following day. Whilst another member of staff on the rota worked several days in the home and then worked the other days in the nearby supported living schemes, therefore not taking a day off for up to twelve days. This was raised with the Manager who explained that staff had often asked to work extra hours. We immediately asked that the rota be reviewed and altered so that staff are not working excessive hours in one stretch. Some staff we spoke with said they were not happy working so many hours and were not keen on working a waking night. This feedback was discussed with the Manager. In addition, the Manager needs to ensure the people living in the home are supported by sufficient numbers of staff. If the Manager was on holiday or off work for any reason, the rota that was viewed indicated that in the afternoon, often until 6pm there would only one member of staff working in the home. At the week-ends the rota showed that there was only one member of staff working the early and late shift. With the home offering places to up to nine people, one member of staff working is not enough to meet the needs of the people living in the home. There are people are need the support of the staff team to go out of the home and this would not be possible if there was only one member of staff working at any one time. Requirements were made for this to be looked at as soon as possible. A copy of the amended rota needs to be forwarded on to the Commission so that we can be certain that this has been fully addressed. Although we recognise it might take time to recruit new members of staff, if this is what is needed to have a home that safely meets the needs of the people living in the home then this needs to be acted on. The safety of both the people in the home and the staff team needs to be paramount when planning a rota and the Manager must ensure that the staff team recognise the hours they need to work and when they need time off to rest. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 22 We viewed three staff employment files. We noted that on one file there were two references but these were not from the person’s most recent employer. This was discussed with the Manager as this needs to occur wherever possible, so that the Manager has current information about the applicant. Two files viewed had some unexplained gaps of employment in their completed application form. One of the references on a file seen was a character reference and this person who had provided the reference had not been named on the application form. It is vital that the Manager and Provider check the information provided and record if they have sought information, along with the reasons why, from other sources that are not named on the application form. All other checks were in place. To ensure the safety and well being of the people living in the home, the recruitment checks need to be robust. We will check another sample of files at the next inspection visit to ensure the checks are more detailed. We looked at the training provided for the staff team. There were individual training records but it was not clear exactly what training staff had attended. One record viewed did not record all the training, as a certificate was seen on safeguarding that had not been recorded on the record. Another record showed that the member of staff had not attended training since 2006. Individual training records, if kept up to date, are an easy way to follow and review the training attended and outstanding for each member of staff. This also provides clear evidence of exactly the training provided to the staff team and can highlight where there is a need for additional training. Staff had not attended any mental health training and this is an important subject that staff need to be informed about. This was discussed with the Manager and a requirement was made for the training programme to meet the needs of the staff team and consequently the people who live in the home. New staff receive an induction to the home and evidence was seen that this is in place. We discussed with the Manager the benefit in recording when new staff have shadowed existing members of staff so that there is a clear record of the induction process. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 & 42 were assessed. 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. Overall the home is well managed. The views of the people living in the home are obtained. Overall the health and safety checks are in place. Individual fire risk assessments need to be completed. EVIDENCE: The Manager has been in post for almost four years. He has an up to date management qualification. During the inspection the Manager was receptive to the findings and was responsive to the comments made. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 24 We were informed that people living in the home complete surveys so that they can voice their opinions about the home. We viewed the feedback recorded about the recent surveys. House meetings are also held on a monthly basis. Those people asked said they have the opportunities to speak about their views of the home. We viewed a short report the Manager had completed about the home. We had not seen a Regulation 26 report for many months. The Manager could not locate recent reports that need to be completed by the Provider, if they are the people visiting the home under this Regulation. These reports should be in the home and available for inspection as they form an important part of monitoring the running and care provided in the home. We viewed a sample of health and safety reports and checks. The fire officer had visited in August 2008 and had not made any recommendations. A fire risk assessment had been completed in July 2008, which looked at various areas of the home, such as smoking risks and fire exits. It was noted in the records of the fire drills that some people do not respond to the fire practices. Each person living in the home must have an individual fire risk assessment completed so that staff are informed and aware of the potential risks present if a person refuses to evacuate from the home. Other checks viewed, Gas Safety Record, Portable Appliance Teat and Electrical Installation test were all up top date. The home had not had its water checked and tested for Legionella since 2006. We advised the Manager that needed to be more often and with a risk assessment in place to demonstrate the ways the home seeks to minimise the risk of this being present in the home. The Manager agreed to ensure a test would be arranged as soon as possible. Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 2 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 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Version 5.2 Page 26 Positive Community Care DS0000073029.V374971.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. 2. Standard YA9 YA20 Regulation 13 (b)(c) Requirement Timescale for action 18/05/09 01/05/09 3. YA20 4. YA33 5. YA33 6. YA35 Detailed risk assessments need to be in place for people who self medicate. 13 (2) People must be given their medication as prescribed. Reasons for not administering medication must be recorded and investigated. 13(2) The regular medication counts and checks must be detailed in order to identify any medication errors. 18(1)(a) To ensure the wellbeing of both the people living in the home and members of staff, excessive long hours must not be worked in a row, e.g. working days into waking nights. Consideration also needs to be given regarding the hours worked at both the care home and where relevant the supported living scheme. 18(1)(a) In order to support people safely and appropriately, there must be sufficient numbers of staff working in the team. 18(1)(c)(i) To ensure people are supported by staff that have an understanding of mental health issues, staff need to receive DS0000073029.V374971.R01.S.doc 01/05/09 01/07/09 31/07/09 31/07/09 Positive Community Care Version 5.2 Page 27 7. YA42 13(4)(c) ongoing training and information on this subject. To ensure the people living in 18/05/09 the home are safe, individual fire risk assessments need to be developed that record how, of if, the person responds to a fire drill. 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 YA22 Good Practice Recommendations To ensure there is a clear record of complaints available, a complaints record should be developed. This could then record the number and type of complaint along with any action taken to resolve the complaint. The home should be well maintained with attention paid to rooms needing refurbishing. Recruitment checks should ensure that the references match the application form and that one should be from the most recent employer. An explanation of gaps in employment also need to be recorded. Unannounced regulation 26 visits need to be followed up with a report and this should be in the home and available for inspection. 2. 3. YA24 YA34 4. YA39 Positive Community Care DS0000073029.V374971.R01.S.doc Version 5.2 Page 28 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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