Care Home: Sahara Lodge

Similar services:

• Ashlong House
• Norbury Crescent (30)
• Edenvale
• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Chatsworth Care - Tudor Lodge
• Foxley Lane (121a)

What the care home does well The home provides an overall good standard of care and support. Service users spoken to expressed their satisfaction. One commented that “It’s good here.” While another said “I’m happy here.” Care planning is person centred and of a good standard, as is record keeping generally. Service users are involved in a variety of community based services, and have access to regular leisure activities. The home is well maintained and presents as having a homely atmosphere. What has improved since the last inspection? There have been considerable improvements to the home since the previous inspection, and all twelve of the outstanding requirements were found to have being met. Service users are now free to move around communal areas (where as previously the kitchen had being kept locked). Healthcare appointments are now recorded, as are complaints. Requirements have being met around improving the environment and staff now have access to at least five days paid training per year. What the care home could do better: There are some issues that must be addressed, and a total of two requirements have been made, along with one good practice recommendation. Comprehensive risk assessments must be in place which are subject to regular review, and the home must implement guidelines for the use of psychotropic medications that are prescribed on an as required basis. Key inspection report CARE HOME ADULTS 18-65 Sahara Lodge 143 Earlham Grove Forest Gate London E7 9AP Lead Inspector Rob Cole Key Unannounced Inspection 8th December 2009 09:00 Sahara Lodge DS0000022847.V378704.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. Sahara Lodge DS0000022847.V378704.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 Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Sahara Lodge Address 143 Earlham Grove Forest Gate London E7 9AP 0208 555 3735 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) maria.dziedziurska@saharahomes.co.uk Sahara Homes Limited Manager post vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registration inclusive of basement flat at 141a Earlham Grove The home can accommodate one (1) named service user over the age of 65 years. Date of last inspection Brief Description of the Service: Sahara Lodge is run by Sahara Homes (UK) Limited and is registered to provide accommodation, care and support for nine people with learning difficulties. It consists of two separate units, a semi-detached care home for eight service users and an adjacent basement flat accommodating one service user. Sahara Lodge is aimed at service users with learning disabilities who may also have challenging behaviours. It provides twenty-four hour supervision and support. Sahara Lodge is close to local amenities including a park, shops and leisure services. Forest Gate station is close by and there are good bus routes to Stratford. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection took place on the 8/12/09 and was unannounced. The inspector had the opportunity of talking with service users, care staff and the homes manager and deputy manager were present throughout the course of the inspection. The inspector was also able to observe staff as they carried out their duties. In addition to this the inspector conducted a tour of the premises, and examined records and other documents. Prior to the inspection, the home completed an Annual Quality Assurance Assessment at the request of the CQC. All of this has contributed to the overall inspection process, and to judgements made within this report. What the service does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 6 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. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. 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. Service users are provided with information about the home before making a decision to move in or not. This information is provided through written documentation, and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. Both documents are easily accessible within the home for any service users or visitors to look at. They are written in plain English, and key parts are also in pictorial form to help make them more accessible to service users in order to meet needs around equality and diversity issues. The Statement says “Our prime function is to support our service users in maintaining a maximum amount of independence and control of their lives.” The Statement also includes details of the organisational structure and of the aims and objectives of the home. The Service Users Guide includes details of Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 9 the rights and responsibilities of service users and of the homes complaints procedure. All service users are provided with a contract. These include details of what the fees cover and house rules. Contracts have been signed by the service users and the homes manager. The home has an admissions procedure. There has been one new admission to the home since the previous inspection, and there was evidence that this had taken place in line with the homes procedure. After the initial referral had been made, the manager of the home met with the service user and carried out an assessment of their need. This included needs around mobility, health care and personal care. The service user was then able to visit the home before making a decision to move in. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 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. Care plans in the home are of a good standard, clear and comprehensive. Service users have a large measure of control over their daily lives, and are involved in the day to day running of the home. EVIDENCE: Individual care plans are in place for all service users. These include a pen portrait of the service user and an activities timetable. Care plans are of a good standard, sufficiently detailed and comprehensive, clearly setting out the needs of service users. They are written in the first person, for example one plan states “I love to watch football and criminal films. I am a huge fan of Elvis Presley.” And “Staff will need to explain to me that it is very cold outside and Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 11 ask me to put on my hat, scarf and gloves.” Care plans are signed by the service user to indicate their agreement with and involvement in the plan, and service users spoken to confirmed that they did indeed attend their care planning meetings. Care plans are subject to regular review. Risk assessments are also in place for service users. Risk assessments seen by the inspector covered risks around managing finances, accessing the community and self medicating. In themselves, these were satisfactory, in that they identified the risks and included strategies to manage and reduce risks. However, on being asked if service users were able to take risks, the manager informed the inspector that one service user likes to help prepare food in the kitchen, and that there are risks around this, but that the service user is still able to do this. This is fine as far as it goes, but where there is such a risk, it is expected that a risk assessment has been implemented. These was no such risk assessment for this activity. It was further noted that risk assessments had often not been reviewed in over a year, for example one risk assessment was last reviewed in March 2008. In order to promote the health, safety and welfare of service users and others, it is required that comprehensive risk assessments are in place covering all areas of potential risk to service users, and that these assessments are subject to regular review, at least once every six months. Through observation and discussion there was evidence that service users have a large measure of control over their daily lives. For example, service users are free to get up and go to bed as they choose, (although the home will encourage service users to get up in time to attend various activities and appointments). Service users were seen to move freely around communal areas, and to help themselves to drinks and snacks. Staff were observed to ask service users what they wanted to do during the day, such as going shopping or out for lunch. On the day of inspection two service users were observed to choose a trip out shopping in Stratford. There was evidence that service users have the opportunity of been involved in the day to day running of the home. Regular service user meetings are held. Minutes of these are kept, these evidenced discussions around menu planning, Christmas and activities. To help facilitate service user choice and involvement in these meetings, picture books are used to help plan menus and activities, thus helping to meet needs around equality and diversity issues. The manager informed the inspector that service users are also involved in the recruitment and selection of prospective staff. One service user showed the inspector their bedroom, and in particular the new wallpaper that had been put up. This depicted the logo of the service users favourite football team, and the service user showed pride in this, and was able to confirm that they had been able to choose this. It was however noted that on the day of inspection a new set of dining room chairs were delivered to the home. Although service users said they liked them when they Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 12 arrived, there was no evidence that they had been given the opportunity of choosing them. The manager said that he thought service users had been given this opportunity, but that it was not recorded. It is recommended that the home records where it has involved service users in the decision making process, to evidence that it has taken place, but also to ensure that there is a clear record of the choices that service users have made. Sahara Lodge DS0000022847.V378704.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: 11,12,13,14,15,16 and 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. Service users have regular access to the community, and are supported to live valued and fulfilling lives. Food in the home was of a good standard. EVIDENCE: No service users are currently in employment, although staff informed the inspector that they are looking in to the possibility of one service user getting a job delivering leaflets. Service users are involved in a variety of day services, ranging from five days to two days a week, and on the day of inspection two services users were attending day services. Through these services service users have the Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 14 opportunity to socialise and develop friendships. They also provide the opportunity of participating in a wide range of leisure and educational activities. For example through day services service users are involved in art classes, dance, drama, music, swimming, wall climbing, beauty sessions and five-a-side football. In addition to these day services, the home itself arranges various activities. Several service users attend church on a weekly basis, and one service user is involved with an on-line dating agency. Both of these activities help to meet service users needs around equality and diversity issues. Service users are supported to take part in other leisure activities, such as bowling, golf, the gym, pubs and restaurants and the cinema. The home arranges day trips, recent trips have been to see the Christmas Lights in London’s West End, Colchester Railway Museum and a safari park. A meal out is planned at a local restaurant to celebrate Christmas. Service users spoken to informed the inspector that they were looking forward to this. Service users are supported to go on holidays. Earlier this year service users went to Butlins, and one service user had a weekend break to Manchester, where they were able to see a football match with the team that they support. The service user said that they had very much enjoyed this trip, and hoped to go again. At the time of inspection, two service users were on holiday at Disneyland in France. There are plans to support another service user to go to Florida next year. Photographs were on display in the communal areas of various activities and holidays, service users were happy to point these out to the inspector and reminisce about the activities. Service users have regular access to local services and facilities, such as shops, markets, cafes, banks and the library. Service users use public transport, and the home has its own mini bus which is used to support services users to take part in activities. In-house service users have access to a variety of leisure activities, including television, music, puzzles, in the garden there is a mini crazy golf range, a football goal net and a trampoline, and the home holds occasional parties and BBQ’s. Visitors are welcome to the home at any reasonable hour, and service users are able to visit their family. Service users have access to a telephone they can use in private. Service users are able to plan the menu at their meetings, and records are maintained of menus. These indicated that service users are offered a varied, balanced and nutritious diet. Service users are involved in buying the food, and on the day of inspection one service user was helping to prepare the evening meal for their housemates. The kitchen was clean and tidy, and food was stored appropriately. The inspector was pleased to note that since the last inspection, the home now checks the temperatures for all fridges and freezers used for the storage of food. It was also pleasing to note that the kitchen is Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 15 now no longer kept locked, and service users are able to freely access it when they want. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 16 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 and 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. The home is generally meeting the personal and health care needs of service users. Service users have access to health care professionals, and staff undertake training in the administration of medications. EVIDENCE: Staff provide service users with support with their personal care, although care plans indicate that service users are encouraged to manage their own personal care as much as possible. Service users were all appropriately dressed on the day of inspection. All service users are registered with a GP. Records are maintained of medical appointments, including details of any follow up action required. Records indicated that service users have access to health care professionals as Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 17 appropriate including dentists, opticians and chiropodists. The home seeks to promote healthy lifestyles by encouraging exercise, such as going to the gym. Where continence products are used, they are disposed of in an appropriate manner. Service users have been supported to get a flu jab. The home has a comprehensive medication policy in place, and medications were stored securely in a locked and designated medication cabinet. One service user currently self medicates, and there are appropriate checks in place around this. Another service user is on a prescribed medication. This was appropriately stored and recorded. All staff have undertaken medication training, indeed, on the day of inspection the supplying pharmacist was in the home providing such training. Medication Administration Record charts are maintained, those examined by the inspector were accurate and up to date. However, it was noted that one service user has being prescribed LORAZEPAM TABLETS on an as required (PRN) basis. There were not any guidelines or protocols in place around the administration of this medication. To help ensure that this medication (and others) are only given when appropriate, guidelines must be in place for the administration of any psychotropic medications prescribed on a PRN as required basis. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 18 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 and 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. The home has taken steps to help ensure that service users are safeguarded from the risk of abuse. Staff undertake adult protection training, and appropriate policies and procedures are in place. EVIDENCE: The home has a complaints procedure in place, a copy of which was on display within the home. The procedure is produced in written and pictorial form, to help make it more accessible to service users. Service users spoken to demonstrated a good understanding of whom they could complain to if they so wished. The procedure includes timescales for responding to complaints received. The inspector was pleased to note that since the last inspection the home now has a complaints log in place, which indicated that complaints received are recorded and investigated as appropriate. The home has a copy of the local authorities adult protection procedure, and also its own policy on this subject. This needs to be amended to make clear the homes responsibility to report any safeguarding issues to the host local authority. The homes manager informed the inspector that he was aware of this, and that they intended to amend the policy as appropriate. Most of the Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 19 staff have undertaken adult protection training, and those spoken to demonstrated a good understanding of their roles and responsibility in this area. Some of the newly recruited staff have not yet had this training, but the manager informed the inspector that it is planned they will have this training in the near future. The home holds money on behalf f service users in a locked cabinet. On the day of inspection, the home was having an unannounced audit of its finances by its head office. Records and receipts are maintained of financial transactions involving service users monies, and systems are in place to help reduce the risk of financial abuse taking place. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 20 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): 24,25,26,27,28 and 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. The home is suitable to meet its stated purpose with regard to the physical environment. Service users are provided with adequate communal and private space, and the home was well maintained and homely in appearance. EVIDENCE: The home is situated in a quiet residential street in the Forest Gate area of the London Borough of Newham. The home is close to shops, transport networks and other local amenities. The home is in keeping with other homes in the area. In addition to the main house, a basement flat next door is also part of the registered home, and this flat houses one service user. This flat has its own bathroom, sitting room and kitchen. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 21 Communal areas consist of a sitting room/dining room (the end of which can be portioned of to provide some private space), a kitchen and a spacious garden to the rear of the home. The home was well maintained, both internally and externally, and furniture and fittings were domestic in character. All service users have their own bedrooms. These are not ensuite, but they do contain a hand basin. Bedrooms meet National Minimum Standards on size requirements. The inspector was able to view two of the bedrooms in current use. These were homely in appearance, and decorated to the service users personal taste, for example with family photographs. Bedrooms contained adequate furniture, including table, chairs, wardrobe and chest of draws. Bedrooms had adequate natural light and ventilation, and were centrally heated. Bedding, carpets and curtains were well maintained and domestic in character. The home has one bathroom/toilet and two shower room/toilets. Bathrooms were found to be clean, tidy and free from offensive odours. Bathrooms were fitted with locks that included an emergency override device. The home has taken steps to help reduce the spread of infection. Laundry facilities are appropriate in scale to the size of the home, and hand washing facilities are situated throughout the home. Protective clothing such as gloves and aprons are provided for staff. In the main house COSHH products were stored securely. In the basement flat COSHH products were stored in kitchen cupboard that did not contain a lock. This was brought to the attention of the homes manager, who said that he would make arrangements for a lock to be fitted within a week of the inspection. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 22 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): 31,32,33,34 and 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 home is staffed in sufficiently numbers to meet service users needs, and staff have a good understanding of their roles and responsibilities. Appropriate recruitment checks are carried out, and staff have access to regular training. EVIDENCE: The home provides 24-hour staff support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display within the home, this accurately reflected the staffing situation on the day of inspection. The inspector was satisfied that current staffing levels are adequate to meet the needs of service users. However, as the home currently has two vacancies, staffing levels would need to be reviewed if there were to be any further admissions to the home. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 23 Through observation and discussion there was evidence that staff have built up good relations with service users, and that they have a good understanding of their needs. Staff were observed to interact with service users in a friendly and respectful manner, and instances of positive interaction were seen throughout the day, for example encouraging service users to be involved with preparing the meal, and discussing what activities service users wanted to engage in that day. Service users spoken to expressed satisfaction with the staff. The home has appropriate policies in place around employment related issues, for example on equal opportunities and recruitment and selection, and as has already being mentioned, service users are involved in the recruitment procedure. The inspector checked four staff employment files, chosen at random. These were found to contain all required checks, including references, proof of ID and CRB checks. Over 50 of care staff have achieved a relevant care qualification, and several other staff are working towards such a qualification. It was noted that during the course of the inspection two staff members had a session with their NVQ assessor. It was also noted that the home was providing training around medication to several staff on the day of inspection. Records are maintained of staff training, and staff receive at least five days paid training a year. Recent staff training has included Deprivation of Liberty, First Aid, Moving and Handling and Record Keeping. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43. 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. This is a well run service. Appropriate systems are in place around quality assurance and health and safety management. EVIDENCE: The homes manager has eighteen years experience of working in social care, and they are currently in the process of applying for registration with the CQC. The home also has a deputy manager in place. Both the manager and deputy presented as being approachable, and service users were seen to interact with them in a relaxed manner. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 25 Policies and procedures in the home are of a generally satisfactory standard. Rerecord keeping is also of a good standard, and confidential records are stored securely. Staff and service users are able to access their own records upon request. Care plan reviews, staff meetings and service user meetings all contribute to the quality assurance processes within the home. In addition, surveys are issued to service users to gain their feedback. The results of these surveys are compiled into a report. The most recent report indicated generally very positive feedback from service users. Fire extinguishers are situated around the main building. In the flat, there is a fire blanket but no other fire extinguisher. This was brought to the attention of the homes manager, who said he would arrange for a fire extinguisher to be installed within a week of the inspection. Fire alarms were last serviced on the 18/5/09, and extinguishers were serviced in March 2009. The home tests fire alarms on a weekly basis, and since the previous inspection regular fire drills are now carried out. The home had in date safety certificates for PAT testing, gas safety and electrical installation. Fridge/freezer and hot water temperatures are checked. The home has in date employer’s liability insurance cover in place. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 26 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 3 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 3 3 3 3 Version 5.3 Page 27 Sahara Lodge DS0000022847.V378704.R01.S.doc No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 Requirement The registered person must ensure that comprehensive risk assessments are in place for all service users, covering all areas of potential risk to service users and others. These risk assessments must be subject to regular review, at least once every six months. The registered person must ensure that guidelines or protocols are in place for the administration of any psychotropic medications prescribed on a PRN as required basis. Timescale for action 28/02/10 2. YA20 13 31/01/10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA8 Good Practice Recommendations It is recommended that where service users are given the opportunity of making decisions regarding the home, this is recorded. DS0000022847.V378704.R01.S.doc Version 5.3 Page 28 Sahara Lodge Care Quality Commission Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Sahara Lodge DS0000022847.V378704.R01.S.doc Version 5.3 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!