Care Home: The Old Hall Care Home

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What the care home does well There is a comprehensive assessment process that introduces prospective residents to the home in a gradual way, to make sure that living at the home would be the right decision for them and the people already living at the home. Detailed care plans provide staff with good information about the people they support. There were good risk assessments in place to enable people to be as independent as possible. The home is decorated and equipped to a very high standard, with a comfortable homely atmosphere. Staff are knowledgeable about the people they support and interact with them in a very positive manner. The home`s training programme offers staff a variety of courses including the opportunity to complete an N.V.Q. (National The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Vocational Qualification) in care. They receive regular supervision sessions, which provide them with good support. What has improved since the last inspection? Documents such as the complaints procedure and the Service Users Guide have been introduced in an easy read format so that residents have clearer information about the home and how it operates. People have been given more opportunities for employment and training and more activities have been made available. The recruitment system is more robust and residents now take part in staff interviews so that they have a say in who is employed at the home. What the care home could do better: No requirements were made following this visit. However several areas were identified that would benefit from some attention. Care plans should be developed further so that they reflect how decisions about peoples care have been made and who was involved in the process. They should also contain information about recent legislation that is designed to protect people`s rights and choices and be regularly reviewed to make sure that the planned care is meeting people`s needs. There should be policies and procedures in place covering all essential subjects so that staff have the information and guidance they need. This includes subjects such as food safety, accidents to residents, clinical procedures and privacy and dignity. There should also be a policy and procedure about how the company will gain peoples views and make sure that systems are being followed correctly. This will enable them to evaluate how the home is operating. Key inspection report CARE HOME ADULTS 18-65 The Old Hall Care Home Chapel Road Fiskerton Lincoln LN3 4HD Lead Inspector Dawn Podmore Unannounced Inspection 8th April 2009 09:30 The Old Hall Care Home DS0000063061.V374963.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. The Old Hall Care Home DS0000063061.V374963.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 The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Hall Care Home Address Chapel Road Fiskerton Lincoln LN3 4HD 01522 595395 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) www.homefromhome.com Home From Home Care Ltd Mrs Jane Bellamy Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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: Learning Disability - Code LD The maximum number of service users who can be accommodated is 10 17th April 2007 2. Date of last inspection Brief Description of the Service: The Old Hall is located in the village of Fiskerton, which has limited local facilities, but it is situated close to Lincoln with public transport links. It also has its own people carrier to enable residents to go out into the community. The home accommodates up to 10 people with a learning disability aged between 18-65 years of age. The main house accommodates 7 people in spacious rooms with en-suite facilities. Three of these are suitable for accommodating people who use wheelchairs. Three bungalows have been built within the ground to accommodate people who are more independent. The gardens are enclosed, with a patio area, and there is car parking to the front of the house. At the time of the inspection the manager confirmed that the weekly fees ranged from £2,067.27 - £2,106 depending on the residents assessed needs. Additional charges are made for things like hairdressing, chiropody, aromatherapy, outings, and toiletries. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report, is available at the home. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This key inspection was unannounced and took any previous information held by C.Q.C. about the home into account. Throughout this report the terms we and us refers to the Care Quality Commission (C.Q.C). Before the visit the provider had returned an Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans for improvement over the next twelve months. We also sent out surveys to residents and staff, 2 of which were returned in time to be included in this report. The main method of inspection used was called case tracking. This involved selecting a proportion of residents and tracking the care they received through the checking of records, discussions with them and the staff who care for them, and observation of care practices. A partial tour of the home was also conducted, which included looking at some bedrooms, communal areas and bathing and toilet facilities. Documentation was sampled and the care records of the three people being tracked were examined. We observed how staff interacted with the residents with limited communication skill and spoke to 2 visitors. Three members of staff were also interviewed. They shared their views about how the home operated on a day to day basis and the support and facilities provided. The manager was available during the visit and the general outcomes of the visit were discussed with her. On the day of the visit 3 people were living at the home. What the service does well: There is a comprehensive assessment process that introduces prospective residents to the home in a gradual way, to make sure that living at the home would be the right decision for them and the people already living at the home. Detailed care plans provide staff with good information about the people they support. There were good risk assessments in place to enable people to be as independent as possible. The home is decorated and equipped to a very high standard, with a comfortable homely atmosphere. Staff are knowledgeable about the people they support and interact with them in a very positive manner. The homes training programme offers staff a variety of courses including the opportunity to complete an N.V.Q. (National The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 6 Vocational Qualification) in care. They receive regular supervision sessions, which provide them with good support. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 & 2 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. Prospective residents have access to the information they need to decide if the home can meet their needs. The home has a comprehensive system in place to assess peoples needs prior to admission. This means that people can make sure that the home can support them appropriately before they move into the home EVIDENCE: People have access to clear information about the home, this includes the Service Users Guide and Statement of Purpose, and the former is also available in an easy read format. A review of all information available prior to this visit, and the content of people care records, showed that the home does not admit people without a comprehensive assessment of their needs being completed. The assessment record of a new resident showed that information had been collected about their needs and what support they required. This included potential risks and their expectations from the home. The manager said that a transitional period would include assessment meetings, which included taking photos of the home so they could discuss the The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 9 facilities available. They also try to arrange for trial visits, so that people can look at the home and meet the residents and staff. This can include short visits and an overnight stay if possible. This also gives the people already living at the home an opportunity to express their views on prospective residents suitability. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are empowered to make choices about their lives and supported to lead their lives as they prefer. Care plans provide a person centred approach to providing the right level of support while acknowledging that people can take responsible risks. EVIDENCE: We looked at two support plans for people with different needs. They were written in the first person and contained comprehensive information about people’s needs and preferences and how they decided to spend their time. This provided staff with a person centred approach to delivering their support. Risk assessments were included in people’s files identifying areas of potential risk. Plans included behavioural triggers and told staff how to manage any incidents. Identified areas of potential risk had then been incorporated into the care planning process. However the decision making process about the use of The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 11 a lap belt to stop one residents from falling out of his wheelchair had not been documented in enough detail to show that its use was in his best interest. The care staff had completed detailed records of how each person had spent their day. There was no documentation available to show that care reviews had taken place 6 monthly as planned. However this had been identified in an internal audit as an area that needed to be addressed. The home has not yet included the content of the Mental Capacity Act into the care planning process, but staff had received training in this subject. This is new legislation that is aimed at protecting peoples rights and choices. Residents available on the day of the visit had limited communication skills so could not fully express what they thought about the home, but they appeared content, happy and well cared for. Two visitors told us that they were very happy with the care and support provided. One said, ‘they looked after him really well from day one’. There is a keyworker system in place so that each resident has a named person they can relate to. Staff were knowledgeable about the people they supported and the need to encourage independence. They described how they tried to make sure that residents were as involved as possible in making choices about their daily lives. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 12 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: Standards 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. Residents are supported to follow their chosen lifestyle and have access to a variety of leisure activities, which have been arranged to meet their individual needs. They also benefit from being able to choose from a varied and balanced menu. EVIDENCE: Each resident had a support plan for meeting his social needs. Files also contained a suggested plan of weekly activities. The manager said that this was to guide staff but was not routinely adhered to as things might change. The records we saw showed that various stimulation had been provided including, shopping trips, bowling, swimming, Club 87, play zone, sensory therapy, outings and walks. There are 2 activity areas, one that has a sensory The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 13 room. Other stimulation available included a piano, potter’s wheel, knitting machine and a computer. In one room a residents parents showed us a project that he had completed with the arts and crafts person. They said that this was to help remind him of the people in his life. He also had a ball pool and an activities box in his room. The manager said that from September there will be opportunities for residents to attend day sessions at some of the company’s other homes This will include activities such as pottery and crafts. Drama workshops were advertised on the notice board through April and May. The home is also registering as a National Proficiency Testing Centre. This is a City and Guilds recognised qualification for service users in life skills, which can be completed by residents at the home. Staff said that they were currently working with residents to develop holiday arrangements. A relative told us that trips to Centre Parks and Butlins had been very successful in the past. The manager confirmed that the company pay £410 towards holiday days; this could be a week (7 days) away, 2 long weekends or 5 day trips. She also said that the company paid for staff to accompany them as necessary. One resident is employed by the company to maintain the gardens. We saw another resident helping to set the table at lunchtime. Staff demonstrated a good knowledge of the support people needed and what they could do themselves. They were seen to include residents in decision making during the day and interacted very positively with them. Records showed that the home offers a varied menu and that residents are involved with choosing what is on it. At lunchtime staff interacted very well with residents and offered support as needed. Visitors were invited to eat with the residents and there was a very relaxed homely atmosphere. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Residents have access to a range of local healthcare services; and their personal healthcare needs are responded to in an individual manner by a knowledgeable staff team. People are able to manage their medications themselves if they can, but if they need help staff are trained to support them with it in a safe way. EVIDENCE: A health assessment had been completed for each resident. Hospital passports had also been completed so that a record of each resident’s health history can be taken to appointments. Staff knew about people’s medical conditions and understood their responsibilities in supporting them. Although residents were unable to tell us if their health needs were being met, records and peoples comments showed that they had access to outside agencies such as specialist nurses, doctors, chiropodists and opticians. The parents of one resident confirmed that they The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 15 were happy with the arrangements made by the home. They also told us, ‘they always ring us and tell us if anything has gone on’. Records and discussions demonstrated that the home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. Although there were no residents looking after their own medications when we visited systems are in place for this to happen. The pharmacist last audited the medication system in December and raised no issues. The only area that needed attention was that a new fridge thermometer was required and this had been obtained. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Residents are protected by clear policies and procedures for handling complaints and allegations of abuse. EVIDENCE: The home has a complaints procedure, which tells residents and relatives how to make a complaint and how it will be handled. A copy is given to all new residents as part of the Service User Guide, which is available in an easy read format. Information provided by the manager showed that the home had received 7 complaints over the last year; none of which were upheld. The people we spoke with said that that they had no complaints. However they said that if they did have any concerns they would be comfortable speaking to the manager about them. The home has a policy and procedure about safeguarding people from abuse so that staff know what they should do if they have any concerns in this area. When concerns had been raised the home had taken actions to safeguard the people concerned and alerted the appropriate people, such as social services. Training records, as well as staff comments, demonstrated that staff had received training on this subject. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 17 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): Standards 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 live in a very well maintained, clean, comfortable and homely environment, which offers a very high standard of décor and furnishings. EVIDENCE: The home has been decorated and furnished to a high standard providing a homely environment. There are two sitting areas, one that includes the dining area. The kitchen is also in the same open plan room, which enables staff and residents to interact throughout the day. Resident’s rooms were personalised and seemed very much as the resident wanted them to be with a very ‘lived in’ look. Relatives spoken with said that they were happy with the facilities provided at the home. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 18 The gardens are well maintained with raised beds and a greenhouse. There are places for people to sit and residents are encouraged to be involved in maintaining them. Three bungalows are included in the registration for the home; these have been built to enable people who are able to be more independent. However there is a system in place so that they can be supported by staff should the need arise. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 19 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): Standards 32, 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. Procedures for the recruitment of staff are robust and therefore offer protection for people living at the home. Staff have access to training and support to help them meet the needs of the people they care for. EVIDENCE: We looked at the recruitment files for two new staff, which showed that all essential checks, such as obtaining written references and C.R.B. (Criminal Records Bureau) checks had been made prior to staff starting work. These are carried out to make sure that potential staff are suitable to work with vulnerable people. Staff comments and the content of the AQQA confirmed that the correct recruitment process was being followed. Staff had received an induction to the home, which included completing a booklet and shadowing experienced staff until they were confident in their role. They told us that they had also attended essential training in subjects such as medications, infection control, person centred planning, risk assessment, manual handling, Mental Capacity Act and fire awareness. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 20 Records and staff comments demonstrated that other training had been provided. This included, SCIP (Strategy Crisis Intervention Prevention), basic food hygiene, the protection of vulnerable adults, autism and learning disabilities. Information provided by the manager showed that out of 12 staff 1 person had completed an N.V.Q. (National Vocational Qualification) in care and 2 others are currently doing the course. Records and staff comments showed that staff support sessions and meetings had taken place and that they had received an annual appraisal. Staff were observed speaking with people in a patient, kindly and supportive way, interacting well with the residents. Relatives were happy with the staff and the way in which they supported people. One person told us, ‘the staff are good, we have no concerns’. Staff said that they felt that they were well trained and supported. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 21 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): Standards 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. Good leadership and guidance is provided to staff to ensure that support to residents is delivered in a consistent manner. The home is managed in the best interest of the residents. There are systems in place to make sure that peoples health, safety and welfare needs are met, but shortfalls in policies and procedures could put people at risk. EVIDENCE: Since the last inspection Jane Bellamy has been registered with us as the Registered Manager for the home. She has experience in managing a care home and will be responsible for its day to day operation. People told us that they were happy with how the home was run and found the manager available and approachable. The parents of one resident were full of The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 22 praise for the staff and the home in general. They said, ‘we used to worry all the time, but as soon as he came here he settled in’. They also said, ‘we would never want him to move’. Staff were also complementary about the manager. They said that they felt the home was well run and they were well supported. One person said, ‘we never use to get support, but Jane is fantastic, supporting and a leader who shows us what needs to be done and how’. Other comments included, ‘we work well as a team’, ‘management is good, much better than it used to be’, ‘I am proud to work here’ and ‘the manager is approachable, reasonable and available’. The company do not have a quality assurance policy or procedure. The manager said that in the past surveys had been sent out to ask peoples opinion, but none had been issued over the last year. Some residents participate in a group called ‘Our Voice’ which is a forum for them to give their opinions on things that affect their lives. Records and peoples comments also showed that residents had meetings to discuss various topics, such as menus, activities and changes in the home. Staff meetings had also taken place. Monthly visits had been made by a representative of the company to assess how the home was operating and a recent audit had taken place. This provided the manager with an action plan to meet identified shortfalls. Prior to this visit the management had raised concerns about how people’s monies were being recorded and safeguarded. Therefore they have recently introduced a more robust system for accounting for how people have spent their money. We looked at how this had been implemented, which included detailed records and traceable receipts. The importance of the company maintaining a robust audit system was also discussed. The home has health and safety polices and procedures to guide and instruct staff. However the AQAA showed that some important policies were not available, such as food safety, accidents to residents, clinical procedures and privacy and dignity. There is also a programme in place to service and maintain equipment in the home on a regular basis. Information provided in the AQAA and sampling on the day of the visit demonstrated that regular checks on equipment, such as fire equipment and gas appliances had taken place. The kitchen has been awarded a 4 star rating by Environmental Health, the highest rating being 5 stars. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 23 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 X 3 4 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 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 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 2 2 3 X Version 5.2 Page 24 The Old Hall Care Home DS0000063061.V374963.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 YA6 Good Practice Recommendations It is recommended that support plans include reference to the Mental Capacity Act, 2007 and the effects it has on resident’s lives. This is to help to make sure that their rights and choices are protected. Peoples planned care should be formally reviewed at least every 6 months so that its effectiveness can be evaluated. It is strongly recommended that the decision making regarding the use of any restraints, such as lap belts, are appropriately recorded and include the outcome of best interest meetings. This will help to demonstrate that people’s rights and choices are being respected. A quality assurance policy and procedure should be developed that outlines how the home will consult with people and monitor its systems. This will help to demonstrate that the home has a structured process for seeking people’s views and making sure that systems are robust. DS0000063061.V374963.R01.S.doc Version 5.2 Page 25 2. 3. YA6 YA7 4. YA39 The Old Hall Care Home 6. YA40 Policies and procedures should be developed for any essential areas not already covered. This will help to ensure that staff have access to essential information about how the home intends to operate. The Old Hall Care Home DS0000063061.V374963.R01.S.doc Version 5.2 Page 26 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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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