Care Home: Roland Residential Care Homes Ltd (Compton Road 6)

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What the care home does well People’s needs are thoroughly assessed prior to their admission into the home. This assists to ensure that people’s individual needs can be met. An experienced capable Registered Manager manages the home. The staff team are knowledgeable in relation to the individual needs of the people living in the home. This improves the quality of care they receive. People living in the home have clear up to date care plans. This ensures that people can be supported in a consistent way as clear guidance with regard to their needs is available. People living in the home make clear decisions about their lives were possible and their involvement in the home is fully promoted. This makes people feel valued. People living at 6 Compton Road undertake a range of activities both in the local community and within their own home which promotes their independence. People are encouraged to have appropriate relationships and maintain contact with family and friends, which promotes their emotional wellbeing. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 People are offered a healthy varied diet, they are encouraged to plan and cook their own meals, which ensures their wishes and preferences are respected. People’s physical and emotional health care needs are met which promotes their health and wellbeing. The procedures in relation to medication are good which further protects the health and wellbeing of the people living in the home. People are protected from potential abuse as clear adult protection procedures are in place, which is supported by a robust recruitment procedure. There is a clear complaints procedure, which indicates that the home takes complaints seriously. There are effective health and safety procedures in place which assist to protect people living in the home. What has improved since the last inspection? This was the first key inspection of this service. What the care home could do better: The registered manager needs to develop a risk assessment for one identified person who may not respond to the fire alarm when sounded and leave the home as required. This will ensure that identified risks are minimised. One identified person needs to have their carpet replaced. This will continue to ensure that the home is well maintained.Roland Residential Care Homes Ltd (Compton Road 6)DS0000072548.V378223.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 Roland Residential Care Homes Ltd (Compton Road 6) 6 Compton Road Winchmore Hill London N21 3NX Lead Inspector Wendy Heal Key Unannounced Inspection 17th November 2009 08:00 Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.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. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.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 Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Roland Residential Care Homes Ltd (Compton Road 6) 6 Compton Road Winchmore Hill London N21 3NX 07956 403643 0208 2114539 Address 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) Roland Residential Care Homes Ltd Amal B.D. Nawarathna Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.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 (CRH-PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 7 Date of last inspection Brief Description of the Service: 6 Compton Road is a home registered to provide accommodation and personal care for a maximum of seven younger adults with mental disorders. The home was first registered on the 11th of June 2009 and is one of four residential care homes belonging to Roland Homes, a company owned by Mr and Mrs Rangetunge. On the ground floor there are two bedrooms one with en-suite facility. The other has a disabled shower and w/c facility available. There is a kitchen-diner on the ground floor. There are three further bedrooms on the first floor. There is a bath There are a further two bedrooms on the second floor. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The rating for this service is good (2 stars) this means that the people who use this service receive good outcomes. This was an unannounced inspection and took place as part of the inspection process. Compliance was checked against key standards and took approximately 10 hours. We undertook a tour of the building spoke with the people who live in the home and members of the staff team. We gained further information from an inspection of the documents kept in the home. This included care plans and health and safety documentation. The provider Mrs Ranetunge, the registered manager and members of the staff team offered their assistance throughout the period of the inspection. We would like to thank the people who use the service and the management team for their openness and participation. What the service does well: People’s needs are thoroughly assessed prior to their admission into the home. This assists to ensure that people’s individual needs can be met. An experienced capable Registered Manager manages the home. The staff team are knowledgeable in relation to the individual needs of the people living in the home. This improves the quality of care they receive. People living in the home have clear up to date care plans. This ensures that people can be supported in a consistent way as clear guidance with regard to their needs is available. People living in the home make clear decisions about their lives were possible and their involvement in the home is fully promoted. This makes people feel valued. People living at 6 Compton Road undertake a range of activities both in the local community and within their own home which promotes their independence. People are encouraged to have appropriate relationships and maintain contact with family and friends, which promotes their emotional wellbeing. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 6 People are offered a healthy varied diet, they are encouraged to plan and cook their own meals, which ensures their wishes and preferences are respected. People’s physical and emotional health care needs are met which promotes their health and wellbeing. The procedures in relation to medication are good which further protects the health and wellbeing of the people living in the home. People are protected from potential abuse as clear adult protection procedures are in place, which is supported by a robust recruitment procedure. There is a clear complaints procedure, which indicates that the home takes complaints seriously. There are effective health and safety procedures in place which assist to protect people living in the home. What has improved since the last inspection? What they could do better: The registered manager needs to develop a risk assessment for one identified person who may not respond to the fire alarm when sounded and leave the home as required. This will ensure that identified risks are minimised. One identified person needs to have their carpet replaced. This will continue to ensure that the home is well maintained. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 7 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. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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 Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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): 2 People using the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home can be extremely confident that their individual needs will be thoroughly assessed and discussed with them prior to them moving into the home. This ensures that their individual needs can be fully met. EVIDENCE: Two people’s files were inspected at random. They indicated when the application form for the identified person was sent to the relevant social worker. There was also evidence noted that the homes induction pack had been forwarded to the relevant parties. The files contained a range of very detailed assessment information. The homes registered manager had worked very hard to ensure that detailed information had been obtained on these individual people. This included documented information from relevant trusts that had forwarded the identified people’s care plans, review reports and relevant letters. The manager had ensured that numerous visits had been undertaken by both him and the staff at the home. This also included attendance on the ward. This was to make sure that as much information had been obtained to ensure that the needs of the individual people could be met. The information recorded included the observations and contact made by Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 10 members of the staff team during various meetings and trial visits. This allows all of the team members working in the home to be actively involved in the assessment process. This benefits the identified person as they experience a professional introduction to the service. The information noted on file indicates that any new person moving into the home would only be admitted to the home after a full assessment of need and trial period had taken place at the identified person’s pace. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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): 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. People’s needs and goals are reflected in their care plan, which assists to ensure that people’s needs can be met. People make decisions about their lives and that increases their independence. People are supported to take risks as part of an independent lifestyle. A further risk assessment needs to be developed in relation to responding to the fire alarm in the event of fire. This will assist to ensure that all risks are identified. EVIDENCE: Two people’s care plans were inspected. The Care Plans are clear to read. The plans record essential information such as date of admission, date of birth, religion, next of kin, key worker and social worker. The care plans have information record on specific areas such as hygiene, communication, domestic skills, daily living skills, community participation, physical and mental health and education. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 12 The care plans are linked to and reflect the assessed needs of the individual people. The plans identify people’s individual needs and there are identified goals that need to be achieved to ensure their needs are met. One care plan inspected identified that a person is given an agreed amount of money each week to obtain his/her own food for meal preparation. The person is encouraged to develop a one week menu with the assistance of staff. Clear guidance is given in relation to how staff are to assist people to achieve their goals within the care plans. One identified person needs particular support with regard to their personal care needs, domestic skills and daily living skills and these are clearly identified within the care plan. There is once again clear guidance to staff in relation to how specific support is to be provided. The interaction between people living and working in the home was positive. On the day of the inspection people were seen taking an active role in the kitchen during the period that the evening meal was being prepared. One identified person was going out independently to undertake an activity in the community. This required some planning and practical support from the staff team which was undertaken in a professional manner. A discussion took place with team members and the provider in relation to possible action that needed to be taken to safeguard the person’s health and wellbeing. There are risk assessments in place for identified people. This is to minimise the potential risks for the identified people living in the home. The risk assessments which were seen on people’s files covered areas such as risk related to current mental health, smoking, behaviour, risk of falls, actions to prevent false allegations and fire. The risk assessments specify the identified risks and confirm the advantages of minimising the risks for specific people. One identified person that does not always respond when the fire alarm is sounded by going to the designated area in the event of fire needs to have the potential risks recorded in a risk assessment. This will ensure that these risks can be minimised. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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: 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. People’s personal development is promoted and encouraged. People undertake appropriate activities which enriches their lives. People are encouraged to maintain their relationships, which promotes their emotional wellbeing. People’s rights are respected which makes them feel valued. People are supported to choose nutritious meals, which benefit their health and wellbeing. EVIDENCE: People living in the home attend external day centres. Other people have an activity plan which has been agreed with them in relation to identified activities they wish to take part in. One person attends a women’s group. Other identified people attend the library, go to the gym undertake swimming sessions. This promotes people’s self esteem and makes them feel valued. The activity plans evidence a range of opportunities to promote and develop Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 14 people’s independence. This includes completing their own menu and shopping list with the assistance of staff members. Identified people cook their own meals from Monday to Friday and have their own identified fridge for the specific items they have shopped for. Other specific people cook for three to four days per week and prepare their own meals. People also develop their social skills by cleaning their own bedrooms, changing their own bedding, setting the table for dinner, dusting their bedrooms. The people living in the home are fully involved in the local community. On the day of the inspection the inspector noted that staff do assist those people that may need support within the local community, which provides people with the opportunity to develop as a person. People go to the theatre, have been to the circus, go to the pub, cafe and goes for meals out within the community. This improves people’s life skills and further enriches their lives. A number of activities are provided within the home people can watch television, listen to music and socialise together. A number of people had been on a group holiday whilst others living in the home had chosen to stay at home and had taken part in day trips. This provides them with new experiences and enriches their lives. People’s religious wishes are respected as one identified person attends the church on Sundays. This promotes the person’s spiritual wellbeing. People living in the home have contact with their family and friends. This assists to promote people’s emotional wellbeing. All of the people living in the home have a key to their bedroom which they use and this was noted on the day of the inspection. This ensures that people’s right to privacy is respected. The menu was made available to the inspector on the day of the inspection. There are also noted choices for those people that cook and shop for their chosen meals. The kitchen was clean and tidy. The fridge and freezer was inspected and this was found to be clean and hygienic. The food identified was labelled and stored appropriately. There were colour coded chopping boards to prevent cross contamination during the preparation of food. This promotes the health and wellbeing of the people living in the home. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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): 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. People receive support in a way they prefer which means their individual rights are being respected. People’s physical and emotional health care needs are met, which safeguards their health and wellbeing. The process for administering medication is effective and promotes the good health of people living in the home. EVIDENCE: The health care records for identified people were inspected. They indicated that people are receiving regular input from healthcare professionals including General Practioners, opticians, CPN’s, Psychiatrists and dentists. This ensures that people’s health care needs are being monitored in a professional manner. The health information was clear and well organised and evidenced clear outcomes of appointments. There was a record of people’s weight charts which are being kept up to date. This means that people’s weight monitoring programme is being effectively Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 16 monitored. This assists to safeguard the health and wellbeing of people living in the home. The people living in the home need varying degrees of support in relation to their personal care needs. People’s preferences in relation to how their personal care is provided are highlighted in their individual care plans which, means their personal wishes are being respected. The registered manager is qualified to perform basic nail care which assists to improve the quality of care for the people living in the home. The medication and medication administration records were inspected. All medication had been signed for on the medication administration record. This supports good practice regarding people’s health. The medication cupboard was inspected and found to be in order. This further safeguards people’s health and wellbeing. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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): 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. People who are living in the home can be confident that their views are listened to and acted upon since the recording of information and action taken in relation to complaints was found to be in order. People are protected by clear adult protection policies and procedures. This protects people living in the home from abuse neglect and self-harm. EVIDENCE: The home has a clear detailed and up to date complaints procedure. This ensures that clear procedures are available for the people living and working in the home. This promotes people’s rights and ensures that complaints are taken seriously. A copy of the homes complaints procedure is displayed in the lounge. The complaints book was investigated and one complaint had been made by an identified person living in the home. The information had been documented had been signed and dated. The inspector was impressed by the professional manner in which the complaint had been thoroughly investigated. People living in the home are provided with a copy of the complaints procedure as part of the service users’ handbook, which is given to people when they move into the home. This assists to promote the rights of the people living in the home. All of the people spoken with individually confirmed they knew how Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 18 to make a complaint if they wanted to and were happy to speak to the manager or staff members if they had concerns. The home had a copy of the adult protection guidance issued by the London Borough of Enfield, the local authority the home is situated in. This ensures that clear guidance is available to the staff team should they need it. The home also has its own detailed protection policy and procedure. The whistle blowing policy was seen. The policy has clear recorded information with regard to how Roland Residential Care Homes will protect people reporting concerns from reprisals or victimisation. This assists staff to feel that their wellbeing will be promoted and protected. The inspector was provided with detailed information to evidence that staff had undertaken adult protection training. This ensures that staff have up to date knowledge and skills in relation to abuse. This assists the staff to protect people from potential abuse. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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): 24,30, 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 living in a clean safe environment, which benefits their health and wellbeing. EVIDENCE: People living at six Compton Road have their own bedrooms. People’s bedrooms were inspected having sought their permission. On the day of the inspection people’s bedrooms were found to be appropriately furnished. The rooms were personalised with people’s own individual items, such as televisions, music centres, bookshelves, pictures and art work completed by them. This assists to make people feel secure and valued in their chosen environment. There are two ground floor bedrooms and both have views over the front garden. There is also fully accessible shower and w/c available for people to Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 20 use which is fully tiled and the equipment provided for use is of a good standard. One identified person needs their bedroom carpet replaced and the provider has agreed to ensure that it is replaced. On the first floor there are three bedrooms one bedroom looks over the front garden and the other two look over the rear garden. This floor also has a bath shower and toilet available to the people living in the home for their use. Once again the bathroom is tiled and maintained to a good standard. Bedroom six is situated on the second floor and looks over the rear garden. Bedroom seven is also located on this floor has views over the front garden. There is a large kitchen- diner where people can eat their meal together if they wish. The kitchen is of a high standard with adequate storage and work areas. It is well equipped with a dishwasher, high level cooker and microwave which ensure that people are appropriately equipped when they are being assisted to prepare meals or are cooking their own meals independently. All of the equipment was functioning correctly on the day of the inspection. There is a chill out area/lounge at the end of the garden were people can relax read listen to music. This area has easy chairs a fridge and plants. This identified area is next to the staff office and is also used for training and team meetings. The kitchen was clean and tidy. This protects the health and wellbeing of the people living and working in the home. The kitchen leads into the garden which is shared by those people living in both number four and six Compton Road. The home is in the process of developing a covered smoking area for people’s use in the garden. The home is comfortable and safe and free from offensive odours. This provides people with a pleasant home to live in. One person spoken to commented, ‘this is the best I have done any were I live I am very happy here’. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35, 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 staff team are able to meet the needs of the people living in the home. There is a robust recruitment procedure that assists people in being protected from potential abuse. Staff are appropriately trained to meet the needs of the people living in the home. The staff are supervised in a professional manner and this assists to ensure that people’s individual needs can be met. EVIDENCE: The home has a staff team in place. The staff can work at any of the provider organisation’s registered homes although they are primarily based at one of the homes. This means that when short term vacancies arise they can be covered without the organisation having to use agency staff. This promotes consistent practice for the people living in the home. The staff rota was seen. There were adequate numbers of staff on shift to meet the needs of the people living in the home. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 22 A number of staff had completed their National Vocational Qualification (NVQ) level 2 and 3 information is clearly documented on people’s files to evidence this. This indicates that over fifty percent of the staff team have undertaken their NVQ. The provider and registered manager for the service are both qualified NVQ assessors. The staff folders showed evidence of a clear induction process that is comprehensive. Staff files indicated that staff had undertaken training in a number of areas that included adult protection, manual handling, infection control, first aid, fire safety, medication, confidentiality, communication and a person centred approach. This assists to ensure that the people living in the home have the necessary training and skills to meet the needs of the people living in the home. The staff recruitment policies and procedures and relevant documentation was inspected and indicated that robust recruitment procedures were in place. The staff files contained criminal records bureau checks (CRB) two references birth certificates and a copy of the person’s passport. These were found to be in order. This assists to protect people living in the home from potential abuse. The staff supervision records were inspected and staff were receiving regular supervision. The staff are also receiving an annual appraisal. This ensures that staff are being supported to work with people living in the home in a consistent way. This assists staff in relation to their own personal development. This benefits the people living in the home as the quality of care is improved and they feel valued. When speaking privately to the people living in the home they confirmed they were happy with the care received. One person commented, ‘they support me well, they are caring’. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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): 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. People living at the home benefit from a well run home. There is a quality assurance system in place that takes into account the views of people living in the home. People’s health and safety is promoted. EVIDENCE: An experienced Registered Manager runs the home. The manager has passed the Registered Manager’s Award. He also has a Masters degree in criminology and psychology. This means that the manager has the skills and knowledge to run the home effectively. The manager was very knowledgeable with regard to the identified people living in the home which assists to ensure their needs are met. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 24 The manager provided the quality Assurance information and there is a clear system in place. The Care Quality Commission is sent regulation 37 notifications of incident forms. This is a legal requirement in place to try to ensure that professional practice is followed. A range of health and safety information was inspected that included a gas certificate, electrical installation certificate, portable appliance testing certificate, fire evacuation procedures and servicing and testing of the home’s fire fighting equipment. The home has an up to date fire risk assessment. The home also has a current public liability insurance certificate. All of the records were found to be in order. This indicates that the home takes health and safety seriously which promotes the health and safety of the people living and working in the home. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 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 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000072548.V378223.R01.S.doc 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.3 Page 26 Roland Residential Care Homes Ltd (Compton Road 6) 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 YA9 Regulation 15 Timescale for action The Registered Manager must 12/12/09 ensure that the identified person that does not always respond to the sound of the fire alarm has a risk assessment developed to ensure that all identified risks are minimised. Requirement 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 YA24 Refer to Standard Good Practice Recommendations The registered person should ensure that the identified person’s bedroom carpet is replaced. This will continue to ensure that the home is well maintained. Roland Residential Care Homes Ltd (Compton Road 6) DS0000072548.V378223.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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