Care Home: St Andrews Court

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• The Lodge Nursing Home
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• Sunnycroft
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• Church Terrace Nursing & Residential Home
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What the care home does well The service is well rung and people are provided with a clean, homely and very well maintained environment in which to live. Care is provided by a competent and trained staff team who meet people’s needs in accordance with their individual plans. There are suitable arrangements in place to support people to live the lifestyle they choose, maintain relationships with family and friends and access community-based services. People are encouraged to express their views and there are systems in place to protect them from harm or abuse. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 What has improved since the last inspection? The service has met the requirements and recommendations identified in the last inspection report. The service has reviewed people’s files to make it easier to access information. Risk assessments and action plans have been produced, where required, in conjunction with care plans. People have been provided with more regular opportunities to meet together to discuss the day-to-day running of the home. Medication procedures have been revised and competency checks are carried out on staff practice to ensure these are being followed appropriately. A matrix has been produced to ensure training undertaken by staff can be monitored more effectively and future training needs identified to ensure staff have the skills to meet people’s needs. Fire drill records include the names of people who have participated providing better evidence that all staff, including new workers and night staff, have received guidance in the event of a fire. What the care home could do better: The service should ensure accurate records are kept of the time medication is taken and discuss with the person’s consultant about any possible implications to her/his health if regularly taken at times other than prescribed. The manager needs to make sure that she continues to improve the service’s quality assurance system to identify areas of development and for people to be fully confident their views are listened to and acted on.St Andrews CourtDS0000028406.V377615.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 St Andrews Court 53 Beeches Road West Bromwich West Midlands B70 6HL Lead Inspector Linda Elsaleh Key Unannounced Inspection 5th August 2009 09:00 St Andrews Court DS0000028406.V377615.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. St Andrews Court DS0000028406.V377615.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 St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service St Andrews Court Address 53 Beeches Road West Bromwich West Midlands B70 6HL 0121 553 4700 0121 5534200 pmclarenhouse@aol.com 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) Mrs Paulette Shirley Provider in day to day control Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places St Andrews Court DS0000028406.V377615.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 (Code 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 (MD) 12 The maximum number of service users who can be accommodated is: 12 11th August 2008 Date of last inspection Brief Description of the Service: St Andrews Court is a privately owned residential home registered to provide 24 hours care and support for twelve people experiencing mental ill health. The home aims to provide an intensive rehabilitation service to enable users to return to living independently. The three-storey property occupies the end corner of Beeches Road and is similar to other properties in the area. It is within walking distance of the town centre, local shops, and post office, and is easily accessible from the M5 motorway. Parking is available at the front of the home and there are extensive gardens at the rear. On the ground floor are two bedrooms with showers, four separate WCs (two for staff use), lounge, quiet room and a smoke room. There is also a large kitchen, dining area, office and staff room. Laundry facilities are separate and there is a storeroom where the food stocks are kept. On the first floor are seven bedrooms three with en-suite showers, a toilet, and bathroom with toilet, shower and bath. The second floor has three bedrooms two with en-suite showers and a separate bathroom with toilet and shower facility. All bedrooms have en-suite toilets. The home also has a separate kitchen and smoking room for people to use and a treatment room. The home should be contacted for up to date information about the fees charged for this service. St Andrews Court DS0000028406.V377615.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 star. This means that the people who use this service experience good quality outcomes. We looked at information we have received about the service since our last visit and sent surveys to people who live in the home, their relatives and health and social care professionals asking them to tell us what they think about the home. We received responses from 85 of the people we surveyed. Comments were positive about the service and have been included in this report. The service is required to complete an Annual Quality Assurance Assessment (AQAA). This provides us with information about what has happened in the home during the last 12 months. This was returned to us by the date requested and contained the information we asked for. This unannounced inspection was carried out by one inspector on 5th August 2009. We spoke to the manager, staff and people at the home. We looked at the care files for two people and two staff files in detail as well as other records and documents kept by the service. This was to help us to assess the quality of life for people who live in the home and the service’s performance against the national minimum standards. The atmosphere in the home was relaxed and friendly. We looked around the communal areas and found it to be furnished to a high standard, clean and tidy. What the service does well: The service is well rung and people are provided with a clean, homely and very well maintained environment in which to live. Care is provided by a competent and trained staff team who meet people’s needs in accordance with their individual plans. There are suitable arrangements in place to support people to live the lifestyle they choose, maintain relationships with family and friends and access community-based services. People are encouraged to express their views and there are systems in place to protect them from harm or abuse. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 6 What has improved since the last inspection? What they could do better: The service should ensure accurate records are kept of the time medication is taken and discuss with the person’s consultant about any possible implications to her/his health if regularly taken at times other than prescribed. The manager needs to make sure that she continues to improve the service’s quality assurance system to identify areas of development and for people to be fully confident their views are listened to and acted on. St Andrews Court DS0000028406.V377615.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. St Andrews Court DS0000028406.V377615.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 St Andrews Court DS0000028406.V377615.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): 1&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. People provided with information they need to make an informed choice about where to live. Their needs and aspirations are fully assessed before they come to live in this home. EVIDENCE: The service has a Statement of Purpose and Service User Guide. These are being reviewed by the manager to ensure these reflect the current conditions at the home. These are made available to people who are considering moving in, their relatives and any other interested parties. There have been no admissions since our last visit. The manager told us referrals to the home are followed up with a visit to speak to the person and carry out its own assessment of their needs. The files we looked at for two people living in the home contained assessments and reports from relevant health and social care agencies. There are records of the trial visits made to the home prior to the person moving in. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 10 We spoke to a person who was staying at the home on one of their planned trial visits. S/he told us they had been visited by the manager who had provided them with information about the service and completed an assessment of their needs. St Andrews Court DS0000028406.V377615.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, 8 & 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. Peoples needs and personal goals are reflected in their care plans. They are encouraged to participate in decisions about their lives and are supported to take risks as part of an independent lifestyle. EVIDENCE: The manager has recently completed a review of how people’s files are compiled to make accessing information easier. We looked at the files for two people in detail. These contained information from relevant agencies and the assessments carried out by the service. The plans detail how a person’s physical, emotional and social needs are to be met. It identifies what each person is able to independently and where they need support. For example St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 12 one person manages her/his own finances whilst the other person requires more support from staff. There is evidence in the recordings made by the service that people are consulted about their plans. More formal reviews are carried out on a regular basis with the person using the service, their relative/representative and relevant agencies for which the service provides a written report on progress. People are provided with opportunities to meet as a group to discuss issues such as the day-to-day running of the home for example the catering/laundry arrangements or agreeing group activities. The minutes of the meeting held in July 2009 shows holidays was the main topic for discussion and the majority of the group agreed they would like to go to Tenby. There is information on people’s files about their capacity to make their own decisions and the efforts made, wherever possible, for people to live the lifestyle they choose. Written agreements have been drawn up between individuals and the service showing areas of responsibility for example the management of a person’s money and/or medication. The service encourages people to live maintain their independence by supporting them to take reasonable risks. The files we looked at show risk assessments have been carried out to identify any risk areas and strategies have been put in place to minimize and manage risks were possible. One person’s file has a risk assessment and risk action plan in respect of their challenging behaviour. Staff we spoke demonstrated they were familiar with risk assessments and actions plans by describing how they would respond to specific risks. Health & social care professionals who responded to our survey commented positively on the service being provided. Two comments received were “will work to the greater welfare and improvement of service users lives” and “promotes well being and minimizes the risk of relapse”. St Andrews Court DS0000028406.V377615.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 are supported to take part in appropriate activities and to maintain links in the local community. They have appropriate relationships and their rights are respected. They are supported to have a healthy diet and enjoy mealtimes. EVIDENCE: People are provided with opportunities to maintain their skills and development new ones by attending college or work placements. One person’s file shows the interest they expressed in improving their academic skills at the time of their assessment was acted on by the support given to them to a suitable college placement and another person is on a work placement similar to the job s/he was doing before they became unwell. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 14 Care plans show the support individuals need to develop their social skills and participate in activities. For example one person plan shows they find some situations stressful and therefore is provided with one-to-one support at these times. A member of staff told us the review report for one person had identified her/his increased confidence in traveling and showed us the care plan had been updated to reflect this. Relatives who responded to our survey tell us the service encourages people living in the home to be a part of community life. One relative commented the service “helps with developing their social skills and confidence”. Visitors are welcome at home; however the deputy told us most people like to go out to visit family and friends. One person makes regular visits to family and plans are being made for them to move to independent accommodation near them. The service has developed good relationships with people’s family and supports contact and regular visits where they can. Information about contact and visits are included in the people’s files we looked at. The surveys completed by people living in the home tell us they are always supported to live the life they choose. Daily living programmes are produced with individuals identifying what they are able to do for themselves and when support is to be provided. For example tasks involved in cleaning their room or providing there own meals. They are able to move freely around communal areas and staff respects their right to privacy when they want to spend time on their own. People are made aware of the service’s ‘no tolerance’ policy in respect of alcohol and drugs. Minutes of group meetings show they are regularly reminded of these. One person who responded to our survey said “food, outings and cleanliness” are areas the service does well. People cook for themselves on specific days and do the necessary shopping needed to produce their meal. Other meals are prepared by staff who are trained in basic food hygiene. The kitchen is well organised and equipped and menus seen show meals are varied and meet people’s dietary needs and personal preferences. The manager told us people are encouraged to follow healthy eating options and the files seen show nutritional assessments are carried out. The service was last inspected by the Environmental Health Agency in March 2008 and no issues requiring action was identified in their report. St Andrews Court DS0000028406.V377615.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 personal support in the way they prefer and require so that their physical and emotional needs are met. They are supported to retain and administer their own medication where appropriate and protected by the service’s procedures and practices for managing medication. EVIDENCE: Care plans for one person shows they require some support with personal care at certain times for example when bathing. Daily notes are kept of the support provided by staff and are monitored by the manager and deputy to check plans are being followed and ensure amendments are made to care plans where required. People’s preferences and how they like to be supported are known by staff. They are encouraged to choose their own clothes and follow their preferred religion. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 16 People living in the home have access to all community-based healthcare services, such as doctor, dentist and optician. Risk assessments are undertaken in respect of their physical and mental health and they are supported to attend appointments. Tracking sheets of all appointments are held on people’s files and detailed daily records are kept to monitor and inform relevant health care specialists about progress. Surveys we received from health care agencies report good working relationships with the service. Comments received include “ensures people’s needs are met”, “encourages independent living skills and responds to requests to amend treatment regimes” and “has a positive approach to our client group”. People’s medication care plans include risk assessments and risk action plans for people who part-manage their own medication. Two people’s medication plans were discussed in detail with a member of staff who demonstrated a good knowledge of symptoms to be aware of and recording processes. The medication administration record (MAR) sheets show people who part-manage their own medication and sign the sheet to confirm they have taken their medication. This is witnessed by a member of staff. However, the MAR sheets does not have space to record when medication is taken at a different time other then when prescribed. It is also advisable for discussions to be held with consultants about whether there are any possible implications to a person’s health if medication is being taken regularly at other times than prescribed. A copy of the service’s safe handling and administration of medication procedures is kept readily available for staff to refer to and includes general procedures for the use of ‘over the counter remedies” and medication prescribed “as required”. Detailed information is kept in the medication folder for individuals who take ‘over the counter remedies” or are prescribed medication to be taken “as required”. There are suitable arrangements for the storage of medication and regular checks are kept to ensure medication is stored at a suitable temperature. We saw records which show staff are trained to administer medication and periodic in-house competency checks are carried out by the manager and deputy to ensure procedures and care plans are being followed appropriately. The records show the pharmacist last visited the service in January this year. No issues where identified as requiring action. St Andrews Court DS0000028406.V377615.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. The service has systems in place to ensure the views of people who live in the home are listened to and acted upon and ensure they are protected from harm or abuse. EVIDENCE: The service has a complaint procedure and details of how to make a complaint are included in the Statement of Purpose and Service User Guide. Information provided to us by the service tells us no complaints have been received by them since our last visit. This was confirmed by the manager and staff we spoke to. People who live in the home and relatives who responded to our survey told us they know who they would speak to if they were unhappy and how to make a complaint. They are also confident any issues raised would be dealt with appropriately. A health care professional reported “Service users feel like it is their home and have a trusting relationship with staff.” No complaints about the service have been reported to us. There are procedures for safeguarding people from abuse and records we looked at show training in this area has provided for staff. A staff member we spoke told us what s/he would do if they had any concerns about a person’s St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 18 safety. Two staff confirmed they had attended training. There have been no safeguarding concerns or referrals during the last twelve months. There are suitable systems in place for managing any monies on behalf of people living in the home and these are known to staff. St Andrews Court DS0000028406.V377615.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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with a homely, clean, safe and comfortable environment in which to live. It is very well maintained and there are good arrangements for infection control. EVIDENCE: The home continues to be decorated and furnished to a very high standard and people have a large well kept garden they can enjoy in fine weather. We looked around the communal areas and no issues were identified that need to be addressed. A person at home during our visit said “I like my room. It has a shower but I can have a bath when I want to”. A member of staff commented the premises was “well decorated and conducive to their [people who live here] care”. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 20 Everyone who responded to our survey stated the home is always fresh and clean. The laundry has suitable equipment and safe arrangements are made for storing cleaning products. Personal protection clothing, such as disposable aprons and gloves, are readily available. The staff team has been trained in the prevention and control of infection and policies and procedures in this area are available. St Andrews Court DS0000028406.V377615.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, 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. People are supported by sufficient numbers of appropriately trained and competent staff to ensure their needs can be met appropriately. They are protected by the service’s recruitment practices. EVIDENCE: We looked at the files for two staff and found records to show good recruitment procedures have been followed. This included the taking up of references and obtaining CRB (Criminal Record Bureau) checks. Each new member of staff is provided with a six week induction programme. The deputy explained the programme which includes a minimum of three days ‘shadowing’ a senior or more experienced member of staff. On completion of a satisfactory induction and initial training the member of staff is registered to undertake the National Vocational Qualification (NVQ). Details provided by the service state 50 of the staff team hold Level 2 or above. The deputy informed us two staff are currently doing Level 2 and four have almost completed the Level 4. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 22 The service keeps a matrix showing all training needed to be attended by each member of staff and further training courses. It shows two training courses have been booked for this month – managing challenging behaviour and basic food hygiene. Staff confirmed they receive a wide range of training that is relevant for their roles. Rotas show staff are provided in sufficient numbers at all times. The manager told us the service does not use agency staff and absences are covered by the team so people are always supported by staff they know and who know them. Regular staff meetings are held providing staff with the opportunity to discuss people’s needs as well as the day-to-day running of the service. The minutes show meetings were held in June and July this year and previously in November 2008. Staff told us “The home is well run” and “The manager is always available if needed”. St Andrews Court DS0000028406.V377615.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 benefit from a well run home where their views are listened to and acted on. Their health, safety and welfare is promoted and protected. EVIDENCE: This service is managed by the owner who is well qualified to run this home. She has fifteen years experience in managing services, holds the NVQ (National Vocational Qualification) Level 4 and the Registered Manager’s Award. She is supported by an experienced deputy and staff commented they are well supported in meeting people’s needs. St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 24 People who live in the home are regularly asked their views about the service and whether or not they are pleased with their care. These are recorded on their individual records and show any action taken by the service. This shows people’s views are listened to and acted on. The service has begun to introduce a formal quality assurance system. The manager and deputy are aware of the need for monitoring its own performance and to analyse and evaluate all the information received in order to produce an annual development plan based on its findings. This will demonstrate more fully that people’s views are listened to and acted upon. We looked the fire records kept by the service. The fire risk assessment is reviewed at least once every year to ensure people who use the building are kept safe. The records show regular fire drills are carried out with the names of people present. The service was last visited by the West Midlands Fire Service in April 2008 and it did not identify any areas of concern. We looked at a random selection of information held in respect of appliances and equipment, such as the portable electrical and gas appliances, These show us appropriate systems are in place to ensure regular checks and servicing is carried out to ensure the safety of everyone at the home. St Andrews Court DS0000028406.V377615.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 3 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 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 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 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 St Andrews Court DS0000028406.V377615.R01.S.doc Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations The actual time medication is taken should be recorded on MAR sheets and discussions held with consultants about any possible implications to a person’s health if taken regularly at times than prescribed. The quality assurance system used by the service should be developed further and include the analysis and evaluation of all the information gathered and produce an annual development plan for the service. 2. YA39 St Andrews Court DS0000028406.V377615.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission West Midlands 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. 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