Care Home: Stocksbridge Neuro-Rehabilitation Centre

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What the care home does well People using the service and relatives acknowledged the good work done at the unit and told us how much better people were and praised the work the service did and the dedication of the staff. Before moving into the service people had their needs fully assessed. This made sure that the staff had the information to make a decision about how people’s needs could be met. Each person receiving a service had a comprehensive care plan, which was reviewed and kept up to date.Stocksbridge Neuro-Rehabilitation CentreDS0000048612.V376510.R01.S.docVersion 5.2Due to the nature of some of the treatments and depending on the stage of recovery there were some restriction on people’s freedom to make choices and their own decisions. Risk assessments were completed and people were supported to take appropriate risk as part of developing independent living skills. People were able to maintain contact with family and friends, however there were limitations placed on this depending on the recovery plan and needs of the individual. People told us that in the main they were satisfied with the food provided and there was evidence that people were offered choices. Records were kept of people’s health care needs and of appointments with health care professionals. People and relatives spoken to told us they were satisfied with this element of their care. Staff told us they were trained and competent to administer medication. Medication was stored appropriately and records were kept of medication received into the home, administration and disposal. Records of complaints were kept and the records showed that complaints were taken seriously. Staff told us they had received training on the protection of vulnerable adults and were able to tell us the action they would take if an allegation of abuse was made to them or if they witnessed an incident. There were procedures in place to make sure cleanliness and hygiene was maintained. The procedure for recruiting staff was thorough and the records showed that procedures were followed. The records showed that staff received the training they needed to do their job. People using the service were surveyed and asked to comment on the service. Staff were able to tell us what action they took on a daily basis to maintain a healthy and safe environment and to reduce the risk of injury to the people they supported and to themselves. What has improved since the last inspection? Observations on the day of the visit, information from staff and people using the service showed that staff responded to calls for assistance in a timely manner. In the main instructions about medication administrations were clear and all medication was securely stored. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 What the care home could do better: The medication monitoring procedures could be improved to make sure people do not run out of medication. Improvements need to be made to the environment to make sure it is more comfortable for people and to make sure furniture and furnishings are maintained to a good standard. In the AQAA the manager had identified areas for further development over the next 12 months. Key inspection report CARE HOME ADULTS 18-65 Stocksbridge Neuro-Rehabilitation Centre 2a Haywood Lane Stocksbridge Sheffield South Yorkshire S36 2QE Lead Inspector Shirley Samuels Key Unannounced Inspection 20th July 2009 09:40 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.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. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.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 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stocksbridge Neuro-Rehabilitation Centre Address 2a Haywood Lane Stocksbridge Sheffield South Yorkshire S36 2QE 0114 2837200 0114 2887736 stocksbridge@schealthcare.co.uk www.schealthcare.co.uk Active Care Partnerships Ltd 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) Kathryn Sandra Oakley Care Home 24 Category(ies) of Physical disability (24) registration, with number of places Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is for service users who require neurological care. The minimum numbers of staff on duty must comply with the staffing notice dated 6/3/00 and attached (referring to previous name of home; Holly Lodge). One specific service user of the age of 17 years and named on variation dated 5th October 2006, with Physical Disabilities / Neurological needs may reside at the home. One specific service user over the age of 65 years and named on variation (V27411) dated 18th December 2006, with Physical Disabilities/Neurological needs may reside at the home. 12th August 2008 Date of last inspection Brief Description of the Service: Stocksbridge Neuro-Rehabilitation Centre is a purpose built service offering respite, assessment and rehabilitation to adults aged 18 - 65 years who have an acquired brain injury or neurological condition. The building has therapy rooms, independent living skills kitchens, lounges for relaxation and access to paved and lawned gardens. The centre overlooks the village of Stocksbridge. It is near the bus routes and the local shops. It is also within easy reach of Sheffield city centre and the motorway network. The building has two levels, with a passenger lift providing access to both. Rooms and corridors are designed to accommodate wheelchairs. The staffing structure consists of an interdisciplinary team of professionals made up of a consultant clinical neurophysiologist, care manager, service manager, nurses, behavioural technicians, two physiotherapists, two occupational therapists, a speech and language therapist and rehabilitation support workers. The ancillary workers such as the cooks, the domestics and the maintenance persons are also employed to support the service. The basic weekly fee is £2,600.00. This includes, nursing care, therapy input as assessed on admission and on reviews, board, lodging, laundry, house keeping, meals, support when attending out patient appointments and a programme of social and recreational activities to complement therapeutic activities. The fee does not include the cost of hairdressing, chiropody, toiletries, maintenance of private equipment, private telephone, internet access, replacement clothing, Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 5 footwear and underwear. Stocksbridge Neuro-Rehabilitation Centre is a part of Active Care Partnerships. At the reception area in the main entrance information is made available about the parent company for visitors and relatives. There is also a folder available with the service user guide specific to Stocksbridge Neuro-Rehabilitation Centre. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means people who use the service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into the report as recommendations- but only when it is considered that people using the service or not being put at significant risk of harm. In future if requirement is repeated, it is likely that enforcement action will be taken. This was an unannounced inspection carried out by Shirley Samuels on the 20/07/09 from 9:40-5:30. The previous inspection at this service took place on the 12/08/08. As part of the visit we sought the views of the people using the service, their relatives, and staff, who we spoke to on the day of the visit. We checked a selection of documents regarding people’s care, and support staff records and records that show evidence of compliance with regulations and standards. Before the inspection the manager completed an Annual Quality Assurance Assessment (AQAA). This information provided by the manager told us how the service had developed since the last inspection and what was planned to further develop the service over the next 12 months. What the service does well: People using the service and relatives acknowledged the good work done at the unit and told us how much better people were and praised the work the service did and the dedication of the staff. Before moving into the service people had their needs fully assessed. This made sure that the staff had the information to make a decision about how people’s needs could be met. Each person receiving a service had a comprehensive care plan, which was reviewed and kept up to date. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 7 Due to the nature of some of the treatments and depending on the stage of recovery there were some restriction on people’s freedom to make choices and their own decisions. Risk assessments were completed and people were supported to take appropriate risk as part of developing independent living skills. People were able to maintain contact with family and friends, however there were limitations placed on this depending on the recovery plan and needs of the individual. People told us that in the main they were satisfied with the food provided and there was evidence that people were offered choices. Records were kept of people’s health care needs and of appointments with health care professionals. People and relatives spoken to told us they were satisfied with this element of their care. Staff told us they were trained and competent to administer medication. Medication was stored appropriately and records were kept of medication received into the home, administration and disposal. Records of complaints were kept and the records showed that complaints were taken seriously. Staff told us they had received training on the protection of vulnerable adults and were able to tell us the action they would take if an allegation of abuse was made to them or if they witnessed an incident. There were procedures in place to make sure cleanliness and hygiene was maintained. The procedure for recruiting staff was thorough and the records showed that procedures were followed. The records showed that staff received the training they needed to do their job. People using the service were surveyed and asked to comment on the service. Staff were able to tell us what action they took on a daily basis to maintain a healthy and safe environment and to reduce the risk of injury to the people they supported and to themselves. What has improved since the last inspection? Observations on the day of the visit, information from staff and people using the service showed that staff responded to calls for assistance in a timely manner. In the main instructions about medication administrations were clear and all medication was securely stored. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 8 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. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 9 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 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 10 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 and 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. Written information was provided about the service and people did not move into the home without having their needs assessed. EVIDENCE: Information about the service was displayed in the entrance and on the units. People using the service and their relatives told us they were provided with information. This made sure that people using the service and people acting on their behalf had the information they needed to help them make a decision. Since the last inspection information in the statement of purpose and other information had been updated. This made sure people received accurate information. In the AQAA the manager told us “Each client has the benefit of a Care/Rehabilitation plan, which is reviewed. The Centre was staffed to meet the needs of young adults with severe and complex brain injuries whose needs cannot be met elsewhere. Should it be necessary additional support or other expertise was made available”. We checked the records of three people using the service. On each of the files Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 11 there were comprehensive assessments carried out before people moved into the home. This made sure that staff had the information they needed to make a decision about whether they could meet people’s needs. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 12 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 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. People had a plan of care. Decisions were made in people’s best interest, risks were assessed and action taken to promote wellbeing. EVIDENCE: In the AQAA the manager told us “Each client has an Individualised Rehabilitation and Care Plan.This is regularly monitored and reviewed at least once a week, at a meeting attended by the Centre’s GP.” “Handover, three times a day ensures staff at all levels are familiar with particular and changing needs. Supervision and discussion about service user issues assist staff in maintaining a positive and informed approach.” Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 13 “Minutes taken at the weekly Interdisciplinary team meetings are made available to all staff/disciplines so that they are aware of issues, goals and the development of treatment plans”. On the visit we looked at three care plans. They detailed people’s requirements and the action staff needed to take to meet people’s needs. Staff when asked were able to point out where information was recorded. Each person had a time table which staff used to trigger particular activities, care and support for individuals . There was a corrolation between the care plan and guidance given to staff and the records of care given. This showed that people’s needs were met according to their plan of care. The records showed there were regular meetings held with all staff involved in the support and care of individulas including consultaion with relatives. Decisions were agreed in the best interest of the person using the service. Risk assessments were in place and formed part of the plan of care. These were regularly reviewed and updated. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 14 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 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. Appropriate activities took place, links with the community were promoted and contact with family and friends was supported. Daily routines met individual needs and people were provided with a balanced diet. EVIDENCE: In the AQAA the manager told us, in the last 12 month the service had continued the recruitment of volunteers. Efforts had been made to promote the involvement of individuals in the day to day activities of the community. He added that daily routines and house rules were designed to promote independence, individual choice and to promote freedom of movement. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 15 The records showed that people’s needs were reviewed regularly. Reviews included consultation with others involved with the individual’s recovery and treatment. Decisions were made about daily routines and the activities to be provided. This showed people’s needs were identified and appropriate action implemented to meet these. Relatives told us they were consulted and informed about decisions and were able to comment. They spoke positively about the service and the therapies used and told us the staff made efforts to explain decisions when these did not always make sense to them. This showed relative were consulted and kept informed. One person using the service told us they were looking forward to moving into a less residential setting and being able to live a more independent life. They also told us they did some voluntary work which they really enjoyed. This showed that staff helped people take up voluntary opportunities. Support and advice was sought regarding personal relationships. Family and friends were able to visit. For some individuals visiting was limited and planned to ensure the wellbeing of the person and to reduce the risk of over stimulation. Nutritional assessments were carried out and formed part of people’s plan of care. This meant staff had the information they needed to make sure people received a diet suitable for their individual needs. People told us that in the main they were happy with the food provided. The records showed that regular discussions took place with people using the service about the food and efforts were made to satisfy personal preference and choice. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 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. People were supported in a way they prefered, their health care needs were met and the medication procedures were reasonably safe. EVIDENCE: Personal support was provided in a way that had been agreed with the person using the service, wherever possible and in consultation with the team of people involved in their care and support. Staff told us where people were unable to state their preference they worked with information provided to them from health care professionals, family and friends. The records showed that people using the service received additional support from a physiotherapist occupational therapist, speech therapist and psychologist. This showed staff provided support in a way that was compatible with people’s preferences and requirements. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 17 People had regular access to health care professionals. People told us visits from health care professionals took place in private. People’s health was monitored any complications and problems were identified and dealt with at an early stage and records of visits and other appointments were kept. This showed people’s health care needs were met. There was a medication policy in place. Staff responsible for the administration of medication were appropriately trained, their competence was monitored and refresher training provided. People’s needs regarding medication was recorded in there plan of care and medication was kept under review. The records showed there were two previous examples of people running out of medication. This could have placed people at risk. Records were kept of all medication received, administered and disposed of and there were safe procedures in place for the storage and administration of controlled drugs. This showed that people were in the main protected by the services policies and procedures for dealing with medication. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 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. People’s views were listened to and they were protected from harm and abuse. EVIDENCE: People told us they had someone to talk to if they were not happy about the service. The records showed that complaints were recorded, investigated and taken seriously. Records of complaints detailed the content of the complaint, the person making the complaint, the outcome of the investigation and any action taken. In the AQAA the manager told us they had received 6 complaints since the last inspection, all were upheld and resolved within the home’s 28 day timescale. This showed that complaints were taken seriously. In the AQAA the manager told us there had been no safeguarding referrals in the last 12 months. Staff told us they had received training on safeguarding adults and were able to tell us the action they would take and what they expected from others. People told us they felt safe and that staff treated them with respect and spoke to them in a way that made them feel comfortable. This showed the home’s procedures protected people from harm and risk of abuse. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 19 Our records showed that the service continued to inform us of any incidents required under the Care Homes Regulations and that they were prompt in taking action to promote people’s welfare and safety. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 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 and 30 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. The environment was clean, however there were some shortfalls regarding furniture and furnishings. EVIDENCE: In the AQAA the manager told us they could do better at redecorating and refurbishing at the agreed intervals. The bedrooms and communal areas were of a size which allowed equipment to be moved around safely. Most of the communal areas lacked a “homely touch”. They were lacking pictures, curtains, soft furnishings etc which would add interest, some stimulation and comfort. The furniture in many areas around the home was in a poor state of repair stained and in need of replacement. Some redecoration of lounge, dining and Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 21 bedrooms had taken place since the last inspection. There were some areas that needed to be decorated to bring them up to standard. This showed the environment could be improved to make it more comfortable and homely. The home was clean. Staff told us they were provided with cleaning materials and equipment to carry out their job safely and to promote good hygiene practice. The laundry was well equipped and the staff said all the equipment was in good working order. Staff told us they had received training on infection control and were able to tell us what action they took on a daily basis to promote a good standard of hygiene. This showed the home was clean and hygienic. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 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): 32,34 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. There were enough trained staff and the recruitment procedures were thorough. EVIDENCE: People spoke positively about the staff. Relatives said the treatment and end results were good and said they appreciated the work that the staff did. People told us that when they called for assistance staff usually responded quickly. They added that they understood that there were others who needed help. This made sure people were attended to in a timely manner. Staff told us, in the main staffing levels were enough to meet people’s needs and to make sure individual activities took place. They acknowledged there were times when due to staff sickness and efforts to cover the rota failed; this could have an impact on people’s programme of activity. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 23 In the AQAA the manager told us numbers of staff were employed to reflect the occupancy and the assessed needs of people using the service. There was little use of agency staff. Agency staff had been used in a way which offered consistency to people for example ongoing one to one support for individuals. Staff told us they received the training they needed to do their job and they received supervision, they were able to identify any additional areas they wanted to develop. Staff training included, fire, health and safety, moving and handling, safeguarding and specialist behaviour management related specifically to people who have a brain injury. The records showed that 71 of staff was trained to National Vocational Qualification (NVQ) level 2 in care. This showed people are supported by competent and qualified staff. The service had a robust recruitment procedure which required submission of an application form, interview, criminal records checks, references, verification of qualification, checks on identification and permission to work in the country. This made sure people were protected by the homes recruitment procedures. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 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): 37,39 and 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 was well managed, the service was reviewed and there were safe working practices. EVIDENCE: Since the last inspection we had received an application to register another manager. The person currently registered would remain working at the home with some managerial and clinical responsibilities. The person who had applied to be registered had worked at the home in a managerial role overseeing the service for some time. This made sure people using the service benefit from a well run service. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 25 Staff told us they understood their role and the role of managers. They told us managers were supportive and approachable. The records showed that meetings were held with staff, people using the service and relatives. These meetings offered people the opportunity to comment on the service and plan ways of improving the service and gaining feedback. The manager told us people were surveyed and asked to comment on the service provided and that regular visits were carried out by the area manager to check on the conduct of the service. During these visits staff, people using the service and relatives are spoken to and their comments recorded and action taken where necessary. This made sure people were able to contribute to the way the service was run and developed. Records showed the fire system was checked regularly, there was an up to date fire risk assessment and staff received fire instruction at appropriate intervals. This made sure staff knew what to do in the event of a fire. Staff were observed working in a way that promoted people’s health and safety. They told us they had received training and the records supported this. Staff were confident using equipment provided and records showed these were serviced regularly to ensure they were kept in good working order. Regular health and safety meetings were held by representatives responsible for safety requirements and records were kept of discussions and decisions. This made sure the health safety and welfare of people using the service and staff was protected by the homes procedures. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 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 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 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000048612.V376510.R01.S.doc 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Version 5.2 Page 27 Stocksbridge Neuro-Rehabilitation Centre 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 YA20 Regulation 13 Requirement The medication monitoring procedure must be thorough. To make sure people do not run out of medication. All areas of the home must be kept in a good state of repair furnished and decorated to a standard that makes sure people live in a comfortable environment. Timescale for action 20/08/09 2 YA24 23 20/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V376510.R01.S.doc Version 5.2 Page 28 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshireandhumberside@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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