Care Home: Spring Gardens, 9

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What the care home does well Strict procedures were in place for assessing and admitting new residents so they can be sure it is the right place for them to live. Good care plans were in place, which residents helped put together. The plans, which have been regularly reviewed and up dated provided staff with all the information they need so that they can support residents in the right way. The resident’s health and personal care needs were well recorded, supported and monitored to ensure they stay well. Procedures at the home make sure that residents are protected from abuse or neglect. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 The inside of the home was clean and tidy making it a pleasant and safe place for residents to live. The home was being well run in the best interests of the residents and staff. What has improved since the last inspection? Person centred care plans, which have been introduced to the home since the last inspection enable residents to have more choice and control over their own lives. Improvements including the refurbishment of the kitchen and bathroom have been made to the inside of the home making it more comfortable for the residents that live there. What the care home could do better: The homes pre-admission assessment, which is required as part of the companies admission and assessment policies and procedures, should be completed in full. Staffing levels of an evening must be increased so that residents are given as many opportunities as possible to take part in activities outside the home. Garden borders should be cleared of weeds making it more attractive for residents to use. Uneven and broken flags in the back garden must be repaired or replaced to minimise the risk of trips and falls. Mirrors should be provided around the home so that residents have the opportunity to use them. Key inspection report CARE HOME ADULTS 18-65 Spring Gardens, 9 9 Spring Gardens Maghull Liverpool Merseyside L31 3HA Lead Inspector Key Unannounced Inspection 19th May 2009 10:00 Spring Gardens, 9 DS0000005275.V375839.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. Spring Gardens, 9 DS0000005275.V375839.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 Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spring Gardens, 9 Address 9 Spring Gardens Maghull Liverpool Merseyside L31 3HA 0151 520 0185 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Expect Limited Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 LD. Date of last inspection 10th June 2008 Brief Description of the Service: 9 Spring Gardens is registered as a care home for three people with a learning disability. There are currently three women in residence. The registered provider for this home is Expect, formerly Sefton Support Services, which is a voluntary organisation. The registered Landlord for the property is Liverpool Housing Trust. The home is a three-bedroom bungalow, which is located in a quiet cul de sac in Maghull. The home blends in well with other properties in the area and is indistinguishable as a care home. The premises are fully accessible and fitted with aids and adaptations. The home has large gardens and is located close to a train station and local shops. It cost £318.00 per week to live at the home. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 star. This means the people living at the home experience good outcomes. This was a key inspection. A key inspection is a planned inspection of the service. The report has been put together using information gathered in a number of different ways, which helped us decide the overall rating of the service. We keep all information we receive about the home in a file, we looked at all the information we have received since the last inspection. We sent out a form to the home called an Annual Quality Assurance Assessment (AQAA). The AQAA has to be filled in and returned to us by a set date usually before the site visit takes place. The AQAA was filled in and returned to us on time and provided us with all the information we asked for about the home. We carried out an unannounced visit to the home, this is when we visit with out any body knowing and is called the site visit. The acing manager and a support worker were on duty at the beginning of the site visit and discussions took place with them both. Discussions also took place with a resident. The acting manager had to leave the home before the site visit had finished, but before she left a project manager (this is somebody that works for the company and is responsible for helping the home managers) came to the home and helped with the rest of the inspection. Due to certain limitations some residents were unable to comment about their experiences at the home, but they were case tracked. This is a process we use to find out whether residents are receiving good quality care that meets their individual needs. It is done by talking to people, looking at results of surveys and reading the records of a sample of people that live at the home to give us a good idea of what it is like for them. Also during the site visit a selection of other records and certificates, which have to be kept in the home by law were looked at and checked to make sure they were up to date and accurate. What the service does well: Strict procedures were in place for assessing and admitting new residents so they can be sure it is the right place for them to live. Good care plans were in place, which residents helped put together. The plans, which have been regularly reviewed and up dated provided staff with all the information they need so that they can support residents in the right way. The resident’s health and personal care needs were well recorded, supported and monitored to ensure they stay well. Procedures at the home make sure that residents are protected from abuse or neglect. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 6 The inside of the home was clean and tidy making it a pleasant and safe place for residents to live. The home was being well run in the best interests of the residents and staff. 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. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 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 Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident’s individual needs were assessed before they moved into the home to make sure it was the right place for them to live. EVIDENCE: Available at the home were a number of polices and procedures for assessing and admitting a new resident to the home they included procedures for admitting a resident in an emergency situation. The AQAA told us that since the last inspection one new resident has been admitted to the home in an emergency. The project manager explained the processes that were followed for admitting the new resident. This included obtaining copies of assessments from social workers and completing there own care needs assessment. Copies of the care needs assessment and a care plan completed by a qualified social worker were in place but some parts of the homes needs assessment had not been filled in. All parts of the homes pre-admission assessment should be completed as required by the homes pre-admission assessment policies and procedures. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have the information they need about how to meet residents needs. EVIDENCE: The company have put together a new person centred care planning format, which they are gradually introducing to all their residential services including Spring Gardens. A person centred care plan enables people using the service to have more choice and control over their own lives. The project manager said all staff have had some training about the new person centred plans. Care plans for two residents were looked at in detail as part of the case tracking process. They covered all aspects of each person’s personal and social support such as personal and health care, independent living skills, accessing the community, relationships and financial needs. The new person centred care plans covered in detail things such as what is important to the person, what they are good at doing, what they like and Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 10 dislike, what they need help with and what they want to happen with their lives. Care plans seen showed that they have been reviewed and updated involving residents and important people in their lives such as their family/representative and staff. A Care Quality Commission (CQC) survey filled in by a member of staff told us that residents care plans always provide them with up to date information about the needs of the people they support. A member of staff spoken with during the site visit said, “Care plans are important because they tell us about the things residents like and how we need to support them in their everyday lives”. Care plans included information about how residents prefer to communicate and how staff need to support them so that they can make every day decisions and life choices such as what to eat and were to go. During the inspection visit staff were seen communicating well with residents. A member of staff spoken with showed a really good understanding of how to ensure the resident’s rights are promoted and how limitations are only put in place for their safety and welfare. Information in the care file and discussion with the manager showed that independent advocates are consulted when necessary. Risk assessments were part of the residents care plans, they have been carried out so that they can take risks safely as part of an independent lifestyle. Risk assessments, which were looked at clearly described the action that staff must take to minimise any risk of harm when supporting residents to take part in certain tasks or activities. Risk assessments, which were looked at had been recently reviewed and updated were needed. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 11 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, 14, 15, 16 & 17 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. Residents live healthy lifestyle but they should all have opportunities to take part in social and leisure activities outside the home during the evenings. EVIDENCE: The AQAA told us that residents are encouraged to make choices about their everyday lives and that they are part of the local community. Care plans, which were looked at included information about residents preferred interests, hobbies and favourite pass times they also included information about the help they need to do these things. One resident is able to make their own choices about what they do and where to go each day and can get out and about without the support of staff. Other residents rely on staff to help them make decisions about what they do each day and they need the full support of staff at all times whilst accessing the community. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 12 Each resident had an activities programme which has been put together based around their assessed lifestyle needs and choices. Discussions with staff and examination of daily records showed that residents are given the right opportunities during the day to take part in their preferred activities and routines but are not always given the right opportunities of an evening. This is because after 6pm on most days of the week there is only one member of staff on duty, which is not enough to support some resident’s lifestyle choices outside of the home. There must be the right amount of staff on duty at all times to provide residents with the support they need to get out and about so that they don’t become isolated. As well as recreational and leisure activities residents are also encouraged and supported to help with small tasks around the house such as cleaning their bedrooms, laundering their clothes polishing and shopping for personal items and food. On the day of the site visit staff were seen encouraging and appropriately supporting residents with some of these tasks. A member of staff explained that one resident in particular is now a lot more involved in daily living tasks around the home, daily records, which were looked at also showed this. One resident commented, “We all are more involved around the house and we do more now” Residents are offered keys to their own bedroom and the front door, although because of certain limitations some residents do not hold their own keys. Each resident had a signed agreement in place about holding keys. Daily records showed that residents are encouraged to maintain contact with family and friends and personal relationships are respected and appropriately supported by staff at the home. Menus, which where viewed at the home showed a variety of healthy meals. Staff said that menus are often changed at the resident’s request. A member of staff showed a good awareness of the importance of nutritious and balanced diets. Care plans included information about resident’s likes and dislikes with regard to food. A good stock of fresh, frozen and tinned food was seen at the home. The kitchen has been refurbished since the last inspection. All appliances and equipment were of a domestic style and in good working order , pots, pans, cutlery and crockery was also of a domestic style and of good standard. A staff member confirmed residents are always involved in the main weekly shop for food as well as shopping daily for essentials such as fresh bread and milk. One resident said,” Yes I shop for a lot of my own food I like to choose the thinks I like”. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 13 Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident’s personal and healthcare needs are well monitored and supported to make sure they stay well. EVIDENCE: Residents care plans included information about the type and level of support they need with personal care as well as their preferred routines. Health action plans, which were part of resident’s plan of care, covered in detail their healthcare, needs and the support that they need to stay well. Records within this section showed that they are offered minimum annual health checks and visits to primary healthcare services such as dentist, opticians and doctors. Residents are also supported to attend specialist services when they need to. Records detailing the visits were available in good detail. Where appropriate visits to the home by healthcare professionals are arranged and recorded. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 15 Communication profiles within care plans show how the person communicates if they are in pain or unwell and the action staff should take in response. During the inspection visit staff were observed assisting residents in a gentle and polite way. Through discussion staff showed that they understood the importance of ensuring residents privacy and dignity one staff member said, “I always knock on doors and shut doors when helping people”. During this inspection visit all medication and medication administration records were examined. Medication and records were stored in a locked cabinet. Discussion with staff and examination of records showed that staff who handle medication have completed relevant training. A policy for the safe handling and administration of medication was availble at the home. The acting manager showed a good awareness of the homes medication polices and procedures. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures were in place for the protection of residents and people were confident about complaining and reporting abuse. EVIDENCE: The AQAA showed that there have been no complaints made at the home in the last year and we have not received any complaints regarding the service since the last inspection. There was a complaints procedure on display at the home. There was also a complaints book to record any complaints made at the home. The Service User Guide and the homes Statement of Purpose also included a summary of the homes complaints procedure. A CQC resident’s survey showed that the person knows how to complain and who to complain to. It also showed that the care staff and the manager always listen and act on what the person says. It was not possible to assess other residents understanding of the complaints procedure due to their limited understanding. The project manager did however state that resident’s advocates and representatives have received a copy of the procedure. A member of staff spoken with said that they knew about the complaints procedure and would be confident about raising any concerns or complaints if they needed to. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 17 Since the last key inspection a referral has been made to Sefton Local Authority safeguarding team. We were notified of this at the time and were satisfied that the correct procedures were followed in the best interests of the residents. It was decided that the company must investigate the incident, their investigation is ongoing and they have kept us up to date with this. During discussion a member of staff showed a good awareness of what to do if they suspected or witnessed abuse. A Protection of Vulnerable Adults procedure was available at the home. The AQAA showed that staff have received Protection of vulnerable adults training. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 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 inside of the home was safe and comfortable but parts of the outside need improving to ensure residents comfort and safety. EVIDENCE: The home is a three bedroom detached bungalow located in a popular residential area of Maghull Merseyside. The home is close to local shops, pubs, health centres and other local amenities including public transport links, Maghull train station is within close walking distance of the home. There are gardens at the front, and back of the house. The home has a garage, which is used for storage and a driveway at the front of the property providing off road parking for several cars. Both front and back lawns were well maintained but the borders were overgrown with weeds, they should be tidied up so that residents have the use of more attractive gardens. Residents are restricted from using a patio area at the back of the home because a Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 19 number of the paving flags are broken and uneven, posing a high risk of trips and falls. These must be repaired or replaced so that residents can use the patio safely. One residents bedroom looked quite bare it was suggested that pictures, ornaments and personal items would give it a more comfortable and homely feel. There were damp patches on parts of the walls in another resident’s bedroom, the resident explained that it has been looked at and she is hoping to have her room decorated in the near future. It was noted that none of the bathrooms or residents bedrooms had mirrors, the service manager was advised to provide mirrors around the home so that the residents have the opportunity to use them. A number of improvements have been made to the inside of the home since the last inspection visit, they include: A newly refurbished kitchen and bathroom, decoration of shared parts of the home and the replacement of furniture in the lounge and sitting room. On the day of the inspection visit residents were seen moving freely around the home. There was a domestic style washing machine in the kitchen, which is used to wash resident’s clothes and bedding. The AQAA showed that the required policies and procedures for control of infection and cleaning routines are in place at the home. It also showed that soiled laundry is washed appropriately and clinical waste is disposed of in the correct way. The AQAA, discussion with staff and examination of records showed that staff have completed training in relation to infection control. There were cleaning rotas in place, which are followed by both staff and residents. At the time of the inspection visit all parts of the home were clean and tidy. Spring Gardens, 9 DS0000005275.V375839.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): 32, 33, 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. Staff are properly recruited and receive the right training to meet the needs of the residents. There needs to be more staff on duty of an evening so that residents have more opportunities to get out and about. EVIDENCE: The AQAA showed that strict staff recruitment procedures are in place and the company is an equal opportunities employer that ensures issues of equality and diversity are thoroughly addressed during the interview process. The AQAA showed that satisfactory recruitment checks have been carried out for all staff that work at the home. Examination of the staffing rota and details provided in the AQAA showed that there are four permanent staff that work at the home and the team is made up of people of various age, and ethnicity. The manager said that there is a sleep in member of staff on duty each night and at least one member of staff on duty throughout the day and evening. Staffing rotas which were looked at showed that there is only one member of Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 21 staff on duty after 6 pm on most days of the week, staffing levels must be increased during the evening for the reasons already explained in the lifestyle section of this report. Discussion with staff, information provided in the AQAA and records seen at the home showed that staff have completed a range of appropriate training and a training programme for future training is in place for each of them. Training covered a range of courses relating to the care and support of the residents and the efficient running of the home. For example first aid, health and safety, protection of vulnerable adults (POVA) and fire awareness. The AQAA showed most of the staff are working towards a National Vocational Qualification (NVQ) Level 2 or above in care. A member of staff spoken with during the visit confirmed the organisation provide a lot of training, which they are always encouraged to attend. Staff records, which were looked at during the inspection visit showed that staff have received induction training when they started work at the home. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being managed in the best interests of the residents and staff. EVIDENCE: There has been a change of manager at the home since the last inspection. The company wrote to us to tell us about this and provided us with details of an acting manager. Mrs Butterworth has been appointed as the acting manager of the home. Before being appointed Mrs Butterworth had worked at the home as a senior support worker for a number of years. The AQAA told us that the acting manager has the qualities and experience to manage the home. The acting Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 23 manager said she has taken part in periodic training to update her knowledge and skills whilst managing the home. A member of staff said, “The manager is very good, she is approachable and understanding” Comments made by residents included, “The acting manager has made many changes, which are for the better”. Systems are in place to ensure the ongoing monitoring and improvement of the service. This includes supervising staff, reviewing administrative procedures and reviewing the residents care plans to ensure their care need requirements are being met at the home. A manager within the company carries out regular audits of the homes systems and procedures to make sure the home is running properly and in the best interests of the residents. The AQAA told us that there are strict procedures in place for handling and recording resident’s money. The procedures, which were discussed with the acting manager have recently been reviewed to ensure that resident’s best interests are completely safeguarded. Residents money and financial records, which were looked at were in good order. The AQAA also showed that all other policies, procedures and codes of good practice, which are required for the service, are available at the home and have been reviewed and updated in the last year. The AQAA told us that equipment used at the home has been serviced or tested as recommended by the manufacturer or other regulatory body and all the required checks have been regularly carried out on equipment used at the home. They include electrical circuits, portable electrical equipment, heating system and gas appliances. A selection of certificates and records, which were seen during the site visit, supported this information. As described in the environment section of this report, the patio area at the back of the home must be repaired to ensure the safety of the residents. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 3 3 3 x 3 x x 3 x Version 5.2 Page 25 Spring Gardens, 9 DS0000005275.V375839.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 YA24 Regulation 23 (b) Requirement Paving flags on the patio, which are broken and uneven, should be repaired or replaced to reduce the risk of people tripping and falling. Staffing levels after 6pm must be increased so that residents are given the right opportunities to get out and about during the evening. Timescale for action 19/09/09 2. YA33 18 (1)(a) 16 (2)(m) 19/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA2 Good Practice Recommendations The homes pre-admission assessment, which is required as part of the companies admission and assessment policies and procedures, should be completed in full. Garden borders, which were untidy, should be better maintained so that residents have an opportunity to sit out in a more attractive garden. DS0000005275.V375839.R01.S.doc Version 5.2 Page 26 2. YA24 Spring Gardens, 9 3. YA25 Mirrors should be provided around the home so that residents have the opportunity to use them. Spring Gardens, 9 DS0000005275.V375839.R01.S.doc Version 5.2 Page 27 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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