Care Home: The Meadows Short Break Centre

Similar services:

• Claremont House
• Coopers Mill Ltd
• Sun Court Nursing Home
• Bramley Avenue (73)
• Paradise Lodge
• Grangewood
• Upaya Ananda
• 15 Bramble Close

What the care home does well This respite care service provides a diverse range of support and care to people with both a learning disability and physical disability, with in excess of 40 families on the register. The four beds within this service are block booked by Hertfordshire Social Services and are allocated through the admissions panel. There are various systems in place, which reflect both professionalism and expertise in working practices. These were observed as appropriate to the needs of the people using this service.The Meadows Short Break CentreDS0000073013.V377602.R01.S.docVersion 5.3The Meadows provides detailed information about the operation of the service to prospective and current residents. The staff team are both committed and enthusiastic in their approach to people living within this service. The environmental standards within this home are exceptional. The service was re-provisioned in 2008 and now provides a respite facility for people with both a learning and physical disability. There has been a considerable amount of thought, care and commitment gone into creating this resource which presents a very homely comfortable place in which people come and stay. Specialist equipment is provided to support people with complex physical needs in using this service. Bedrooms and communal areas are also presented to an exceptionally high standard and private spaces provided are presented in a way which promotes people`s dignity. The staff spoken to during the inspection appeared to have a clear understanding of their individual roles and responsibilities. The service has clearly defined job descriptions. Staff have received a series of mandatory training in order to carry out their roles effectively and professionally. The manner throughout this inspection process was very professional and open, which made this inspection experience a positive one, for everyone involved. What has improved since the last inspection? Not applicable. What the care home could do better: The current care plans could be presented in a more “user friendly” format that ensures that the person using this service is able to fully comprehend and consent to their own care plan.The Meadows Short Break CentreDS0000073013.V377602.R01.S.doc Version 5.3 Key inspection report CARE HOME ADULTS 18-65 The Meadows Short Break Centre The Meadows Short Break Centre 19 - 21 Grove Meadow Welwyn Garden City Herts AL7 2BE Lead Inspector Julia Bradshaw Key Unannounced Inspection 2nd September 2009 10.30a The Meadows Short Break Centre DS0000073013.V377602.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. The Meadows Short Break Centre DS0000073013.V377602.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 The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service The Meadows Short Break Centre Address The Meadows Short Break Centre 19 - 21 Grove Meadow Welwyn Garden City Herts AL7 2BE TBC TBC 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) Jubilee House Care Trust Ltd Alison Mooney Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places The Meadows Short Break Centre DS0000073013.V377602.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 user of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability -Code LD Physical Disability - Code PD The maximum number of service users who can be accommodated is: 4 First Inspection 2. Date of last inspection Brief Description of the Service: The Meadows short break service is located in Welwyn Garden City Hertfordshire and within a quiet residential part of the town. The building is a large refurbished detached property comprising of four bedrooms with en-suite facilities, an office, bathrooms/toilet facilities, a sensory room, lounge/dining room, a kitchen and a utility room. The home also has a large garden to the rear of the property. There is easy access to local transport from the home although most people using the service access the on-site transport provided by the home. All areas of the home have wheelchair access. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection carried out by the Care Quality Commission since the service was reprovisioned and registered in November 2008. The focus of the inspections undertaken by the Commission is based upon outcomes for the people who use the service and their views of the service provided. The primary method of inspection used was case tracking which involved selecting three people and tracking the care they received through looking at their care records, discussion where possible with the people who use the service, the care staff and observation of care practices. The visit was unannounced and planning for the visit included assessment of the notifications of significant events, which had been received from the service to the Care Quality Commission. This included the Annual Quality Assurance assessment (AQAA), which was completed by the manager. This document focuses on how well the service is meeting outcomes for the service users and also provides us with some numerical information. The visit took place over one day and was conducted by one Inspector. This enabled the inspector to directly and indirectly observe the care practices and the day to operations of the service. A selected tour of the building was conducted during which the inspector spoke with people who use the service, staff and visitors. The Registered Manager was on annual leave at the time of this inspection. There is an up to date copy of both the Statement of Purpose and Service User Guide held within the main office of the home. There should also be an up to date copy of the latest Inspection report made available, once this report has been made public. The fee range for the service is not applicalbe. However the fee range is dependant on individual needs. The fee would exclude personal items, hair dressing, some personal choices for trips, newspapers, toiletries and other personal items of choice. What the service does well: This respite care service provides a diverse range of support and care to people with both a learning disability and physical disability, with in excess of 40 families on the register. The four beds within this service are block booked by Hertfordshire Social Services and are allocated through the admissions panel. There are various systems in place, which reflect both professionalism and expertise in working practices. These were observed as appropriate to the needs of the people using this service. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 6 The Meadows provides detailed information about the operation of the service to prospective and current residents. The staff team are both committed and enthusiastic in their approach to people living within this service. The environmental standards within this home are exceptional. The service was re-provisioned in 2008 and now provides a respite facility for people with both a learning and physical disability. There has been a considerable amount of thought, care and commitment gone into creating this resource which presents a very homely comfortable place in which people come and stay. Specialist equipment is provided to support people with complex physical needs in using this service. Bedrooms and communal areas are also presented to an exceptionally high standard and private spaces provided are presented in a way which promotes peoples dignity. The staff spoken to during the inspection appeared to have a clear understanding of their individual roles and responsibilities. The service has clearly defined job descriptions. Staff have received a series of mandatory training in order to carry out their roles effectively and professionally. The manner throughout this inspection process was very professional and open, which made this inspection experience a positive one, for everyone involved. What has improved since the last inspection? What they could do better: The current care plans could be presented in a more “user friendly” format that ensures that the person using this service is able to fully comprehend and consent to their own care plan. The Meadows Short Break Centre DS0000073013.V377602.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. The Meadows Short Break Centre DS0000073013.V377602.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 The Meadows Short Break Centre DS0000073013.V377602.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 -5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the service is kept up to date and provided for all prospective users of this service and everyone wishing to enter the home has a full assessment of need completed. This ensures that all parties can be sure the home can meet all individual needs. The terms and conditions of the home are agreed in writing so that people are clear about the roles and responsibilities of all those in the home. EVIDENCE: The Statement of Purpose is updated and reviewed annually or, as and when required. The Statement of Purpose and Service Users Guide are two separate documents. A copy of the Service User Guide is provided to all service users. A comprehensive assessment is completed for all new service users. It covers all aspects of care needs and the services that are provided to meet them. Referrals are taken directly from Social Services District Teams, or from private individuals. It is the responsibility of the manager or senior staff to carry out a service delivery assessment prior to the service commencing. The assessment includes discussion with the service user regarding needs and The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 10 choices, details of other agencies involved, support mechanisms, risk assessments including medication (where necessary) and to access any other relevant information. The Meadows Short Break Centre DS0000073013.V377602.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): 6-10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans reflect a detailed record of peoples needs, which ensures that people using the service are assessed, receive a service that meets their needs that is also reviewed and safe from risk. EVIDENCE: People living at The Meadows have an individual care plan and an allocated key worker to support them in the service. Detailed pen pictures are in place for each person and provide good information goals, likes and dislikes of the individual. People appeared to have been involved in the development of their support plans and consulted in the way that care is received in terms of preserving rights and dignity. However two of the care plans inspected could be further improved by presenting these in a more “user friendly” format, which can be easily understood by the person using the service. One care plan did not contain a signature of either the person using the service or their The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 12 representative. However, overall the care plans inspected were presented to an acceptable standard. Individual daily notes and guidelines for the people living within the service were available. People who use the service are supported within either the Whole Life Review framework. Risk assessments were in place where an identifiable risk had been acknowledged as part of the person’s overall needs assessment. All risk assessments seen had been dated and signed by the nominated member of staff. Staff work with people to assist them to lead safe and enjoyable lives and regarding decision making and offering support where needed. The Meadows Short Break Centre DS0000073013.V377602.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- 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 who use the service can feel assured that they will be offered and receive appropriate opportunities for social/leisure and community involvement, which meets their needs and expectations. EVIDENCE: Staff endeavour to support service users to continue with the regular activities and commitments they take part in, when they are not in the respite unit. On the day of this inspection people using this service were attending Hornbeams day centre, Oakland’s College and St Michael’s daycentre. Evidence was seen of on-going work taking place between families and care staff from the unit. There are written guidelines on promoting individual choice and staff clearly promote this policy. The parameters of the daily routines in the unit are also The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 14 set out in the information given to service users and their families. The care staff prepares a weekly list of activities and residents are able to take part in these events if they wish. Visits to religious services or to regular therapy sessions would be supported by staff in the home whenever possible. Service users are able to take part in any appropriate local events, with staff support, whilst staying at the Meadows. The AQAA states that “Staff assist service users with attending clubs/church maintaining links with friends, inviting friends over parties”. Appropriate relationships are supported by staff and relatives of service users are involved in all aspects of daily life in the home. Menus were inspected and offer a range of diverse meals that are representative of the cultural needs and wishes of the people currently staying at the Meadows. People are also encouraged to support in preparing meals in the kitchen, as appropriate. The Meadows Short Break Centre DS0000073013.V377602.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 – 21. 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. EVIDENCE: All care provided is individual to each persons needs in line with each persons choices. Assessments are completed ensuring that the approach adopted is person centered and holistic to each person. People are supported with all aspects of their physical and emotional health needs. There are male and female care staff on the staff team and the service is therefore able to fulfil any gender preference an individual might have for staff providing personal care. Appropriate aids and adaptations are in place to promote service user independence and staff work closely with other health professionals where additional support is required. There is always a member of staff with a first aid qualification on duty which ensures the safety of people staying at the Meadows. The procedures for the administration of medication were checked and were thorough to ensure people are kept safe. The service ensures that only competent and fully inducted members of staff administer medication. The The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 16 home’s policy is that two staff administers medication. There is a protocol for the use of rectal valium and the community nurses attending individuals service users make detailed notes, which are maintained within the medication cupboard. No gaps or errors were found on the recording sheets on the day of this inspection. Photographs of service users and details of all medication taken are recorded on entry and relatives sign for the administration of any nonprescribed medication. A new record sheet is produced for each service user, every time they enter the home and documents and risk assessments are completed for residents who self-medicate (where necessary). The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22-23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this service can be assured that they will be protected from abuse and that they will be listened to if they raise any concerns or make a complaint about any aspect of their care. EVIDENCE: The service has a detailed complaints procedure in place. A record is maintained in the service of any complaints made detailing actions and outcomes as necessary. Two people spoken to stated that they knew who to talk to if they had reason to complain. The recent Annual Quality Annual Assessment (AQAA) stated that they were “No Complaints received” ( January 2009). The complaints procedure is also provided in a pictorial format that can be easily understood by everyone using this service. A detailed procedure is in place to ensure that people using the service are protected from abuse and harm. Staff receive suitable and adequate safeguarding training. Staff employed within the home are all subject to enhanced Criminal Records Bureau disclosure. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 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- 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. The environment provided is presented to an exceptionally high standard thus ensuring that people can feel very comfortable, safe and protected. EVIDENCE: This new building and service has only been in operation since November 2008 and is therefore presented to a high specification for the people currently using this service. Throughout the home there has been a considerable amount of care and attention given to ensuring the highest standards are provided to people with complex physical needs, including the very highest specification of specialist equipment in the bathrooms, kitchen, living room and bedrooms. There is also the facility for a “loop hearing” system within two of the bedrooms and in the lounge area, if and when required. Adjustable sinks and baths are provided throughout the home as well as low level and adjustable work surfaces within the kitchen. There is also ceiling tracking throughout the The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 19 home when using individual hoists. There are a variety of communal areas for people to relax in as well as the provision for a “snoozlem” in a separate living area. Bedrooms have been decorated with soft and complimentary colours with matching soft furnishings and accessories. All bedrooms have a flat screen television fitted. The theme created throughout the home is one of a homely relaxed and very welcoming environment. There is a large garden to the rear of the home with easy access for wheelchair users. All health and safety monitoring was up to date, including fire records and hot water temperatures. All areas of the home on the day of this inspection were very clean and odour free. The manager and care staff monitors these standards to ensure a good level of cleanliness is maintained. The kitchen and laundry rooms are domestic in style and appear to manage their current workload effectively. There was adequate hand washing facilities within the service to ensure effective infection control procedures can be followed. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 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): 31 -36. 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. A loyal, experienced and well-trained staff team ensures people using this service are provided with a good level of what and supporting documentation confirmed people are protected. EVIDENCE: The manager and staff team work hard in striving to further develop the standards for the people staying at The Meadows. Recording systems are detailed and comprehensive. Staff training is varied and staff are able to access a range of both diverse and mandatory training. Recent training includes, fire awareness, equality and diversity training, mental capacity act training, infection control and safeguarding training. During this inspection there were several examples observed where staff clearly demonstrated their commitment to their work in caring for the people who use the service, including communicating with a person who was unable to verbalise their needs but staff were seen to be both patient and considerate in ascertaining what the person wanted, however long this may have taken. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 21 Two members of staff spoken to during this inspection stated that they found the manager approachable and the training opportunities were good The rota was checked on the day of this inspection and the service demonstrated that adequate staffing is provided on both day and night shifts. The recruitment records of 2 staff, including the most recent appointment were viewed, evidence demonstrates that there are thorough recruitment practices within this service, which means that people living at the Meadows can be reassured that they are protected by the effective recruitment systems in place. The AQAA states that “The Company has a thorough recruitment process, which includes a personal interview for all staff. The interview is linked to an induction, post probationary period and appraisal”. All staff have individual training programs which includes mandatory and developmental training. This is identified through supervision and appraisals. Staff confirmed that they received a job description on starting employment and they underwent a period of induction which is linked with skills for Care. Staff received regular, recorded formal supervision and appraisals. Although staff meeting records seen were not up to date, staff spoken to on the day confirmed that these meetings are provided on a regular basis. An up to date record of all staff meetings should be made accessible and available, to ensure all staff are consulted and kept up to date at all times, with regard to the running of the service. Regulation 26 visits are carried out on a monthly basis and a record was seen of the most recent visits carried out. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 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- 43. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can be assured that they are protected by the Health & Safety procedures in place and benefit from a well managed home, with a supportive staff team and are protected by the Health and Safety procedures in place. EVIDENCE: The manager of the home is registered with the CSCI and has completed NVQ level 4 training. There is a good working relationship between staff members, which benefits the whole staff team and therefore the service users. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 23 There is a Quality Assurance system in place that includes sending out annual stakeholder and relative questionnaires as part of the Companies annual Quality Assurance programme. The service could further benefit from developing all information that is provided to service users, in a format that is easily understood by all service users and covering all abilities. This information should also be provided on audiotape, where necessary. The manager ensures that supervisions and staff training are held regularly and two staff spoken to on the day of this inspection staff confirmed that they feel very “supported and respected by the manager”. People are safeguarded from harm by the homes recruitment procedures, safeguarding training and the complaints procedure. The manager continues to further develop the Quality Assurance System in all areas of the service in order to ensure there is regular monitoring and reviewing to improve areas of development, with a particular focus on service user involvement. All records inspected were secure and were up to date and held in accordance with the Data Protection act 1998 ensuring that peoples rights and best interests are safe guarded by the homes polices and procedures. Individual and generic risk assessments are in place ensuring that people are kept are safe and protected. The general standard of health and safety including the fire checks is good and fire records on the day of the inspection were up to date and recorded accurate. There are systems in place in order to ensure that everyone living, working or visiting this service are protected from cross infection. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 3 27 4 28 4 29 4 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Version 5.3 Page 25 The Meadows Short Break Centre DS0000073013.V377602.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 YA6 Regulation 15 Requirement The care plan must be created in a format that can be easily understood by the individual service user. Timescale for action 30/11/09 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 The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. The Meadows Short Break Centre DS0000073013.V377602.R01.S.doc Version 5.3 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!