Care Home: The Richardson Partnership for Care

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What the care home does well The home is clean and has a homely atmosphere and is pleasantly decorated. The people and their representatives are able to visit the home and are given information about the services that are offered to meet the people’s needs. One person told us that `they are happy` and have no complaints. Another person said `they look after us well`. A variety of comments were received about the food that was offered to the people. One person told us that `the food is very nice`. Another tells us that ‘I like it here’ and ‘food is nice’ and ‘all staff are nice’. The people tell us that they can have something else to eat if they do not like what is given on the day. The people tell us that if they did not feel well, they would tell the staff and `they will call the doctor`. They also tell us that they know how to complain if they are not happy. The people told us that they like their bedrooms and the rooms seen were individualised to meet the people`s needs The staff tell us that they enjoy working at the home and with the people. It was said `we get on well together’. The staff say that they work very hard to meet the needs of the people. They get lots of training to help them meet the people`s needs. They were observed talking and listening to the people and offering advice in a positive manner. They say they get ‘good support’ from the manager. What has improved since the last inspection? All the people’s bedrooms have en suite facilities and the home has been decorated pleasantly. The home has purchased a new wide TV, and table tennis/ pool table. There is a new lounge with a sink so the people are able to get a drink of water. The home is pleasantly decorated with new furniture and bedding. The home has employed a new manager. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 What the care home could do better: All the people must be provided the opportunity to be involved in drawing up their care plans and to ensure that they are signed by them or their representative. This is so they know how their goals and aspirations will be met. Provide more activities to meet all the people’s needs. Key inspection report CARE HOME ADULTS 18-65 Boughton Green Road 144 Boughton Green Road Kingsthorpe Northampton Northants NN2 7AA Lead Inspector Ansuya Chudasama Key Unannounced Inspection 29th June 2009 09:30 Boughton Green Road DS0000012714.V376474.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. Boughton Green Road DS0000012714.V376474.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 Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boughton Green Road Address 144 Boughton Green Road Kingsthorpe Northampton Northants NN2 7AA 01604 791266 01604 791882 info@careresidential.co.uk 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) The Richardson Partnership for Care Mr Brian Richardson, Mrs Jacqueline Richardson, Miss Laura Richardson, Mr Gregory Paul Cheater Vacant Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 15 10th December 2007 Date of last inspection Brief Description of the Service: 144 Boughton Green Road is situated in the suburbs of Northampton. It is approximately four miles from the town centre. There are facilities such as shops, pubs, banks, and a library not too far from the home. The home offers care for adults who have an acquired brain injury. The home offers care to both male and females between the ages of 18 to 65 years old and accommodates 14 people. The home is a large detached house and has 14 single bedrooms with en-suite facilities. Five bedrooms are on the ground floor. All ground floor rooms are wheelchair accessible. The home has two lounges, one small dining room with one dining table and a conservatory with two dining tables and this over looks into the garden. There is a separate kitchen and a laundry room. Smoking is not allowed in the home but an area has been designated for this purpose. There is a large garden at the rear of the house, where staff offices are also situated. The people have the use of two cars to take them out in the community. There are parking facilities at the front of the house and an enclosed garden to the side and at the rear of the home. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 5 The weekly charges are £2,104.00 per week, this is exclusive of VAT. The charges for purchasing toiletries, clothes, cigarettes, visit to the hairdressers, and other personal items is the responsibility of the person staying at the home. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is home has 2star rating and this means that the people using the service receive a good service. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies which require review of key standards for the provision of a care home for older people that takes account of the peoples views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. We looked at the Annual Quality Assurance Assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment tool that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We also looked at the information from the last key inspection and the records of any other visits that we have made to the home in the last 12 months. Information we have about how the home has managed any complaints and things that have happened in the home, which are reported under notifications and are a legal requirement are also looked at. The report refers to we this is because the report is written on behalf of the Quality Care Commission. We last inspected this service on the 10th of December 07 and an Annual Service Review (ASR) was carried out on the 20th of August 08. This key inspection was carried out on the 29th of June 09. The manager and another manager from one of the sister home helped out with the inspection process. On the day of the inspection there were 8 people living at the home and the home has 6 vacancies. During this inspection we tracked the care of two people who use this service. This involved reading their care records and also talking to them wherever possible to obtain their views on the service. We also spoke to most of the other people who live in the home. Documentation relating to staff recruitment, training and supervision, medication administration, complaints and health and safety were also examined. We had the opportunity to talk to some of the staff who were on duty. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? All the people’s bedrooms have en suite facilities and the home has been decorated pleasantly. The home has purchased a new wide TV, and table tennis/ pool table. There is a new lounge with a sink so the people are able to get a drink of water. The home is pleasantly decorated with new furniture and bedding. The home has employed a new manager. Boughton Green Road DS0000012714.V376474.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. Boughton Green Road DS0000012714.V376474.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 Boughton Green Road DS0000012714.V376474.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): 1,2,3,4,5 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. The people’s assessment needs are carried out prior to admission to ensure that the home is able to meet their needs. EVIDENCE: The home has a detailed Service User Information package for the home and this includes information stated in the Statement of Purpose and this was updated in May 2009. This was good. We were told by the people spoken to that they were given information about the home. One person told us that ‘I visited the home with my carer’ and ‘liked the home’. Another person told us that my ‘social worker got me in’. Other comments include ‘I visit the home to see if I liked the place’. The peoples files looked at showed that there were assessment admission details of the person being admitted to the home. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 11 All the people in the home have contracts. But did not have all the information stated in standard 5. This is so the people understand their terms and conditions of their stay. We were told that this was being sorted and a copy of the new format was seen in the ‘Service User Information Package’. Boughton Green Road DS0000012714.V376474.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): 6,7,8,9,10 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. All the people have care plans but this needed to be further developed to ensure that all the people or their representative are involved in drawing them up so they know how their goals and aspirations are being met at the home. EVIDENCE: We looked at two peoples care plans in detail and discussed their care needs with staff on duty. The staff showed that they had very good understanding of the care needs of the people. We were told that the staff review the people’s care plans on a monthly basis. We were also told that the home has care plan meetings with the people and they had the option to attend the meeting. The care plans seen were detailed and had information about personal and health Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 13 care, and life style information. The information on restrictions being placed on the people was not seen but we were told that this information was being reviewed in line with the Mental Capacity Act and Deprivation of Liberty Safeguards. The plans we saw were not signed by the person. It is important that where possible people sign their care plans as this shows that they have been involved in agreeing how they would like to be supported and cared for. The AQAA says the plan for improvement in the next 12 months is the ‘implementation to person centred planning, to further identify service user aspirations and needs’. The ‘service user satisfaction questionnaire’ read stated that one person ‘would like more involvement’ in their care planning and risk assessment. Another person said that they do ‘not really’ feel involved in their care plan and risk assessments. We were told that all the care plans were going to change to the format of Person Centred Planning (PCP); this was where the people would be involved in discussing their goals, aspirations and dreams. The manager of the home had already sent out information to families, asking them to send information about their relative for PCP meetings. A range of risk assessments are in place that enables the people to take risks as part of an independent lifestyle The people’s information was kept secure in the office. Boughton Green Road DS0000012714.V376474.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, 14, 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. Meals served are nutritious and plentiful with a menu, which changes each week so that the people have a balanced diet with choices to meet their needs. EVIDENCE: We were told that one of the people had a 50th Birthday party at a pub. The people from the other sister homes and staff and friends were invited. It was said that every body enjoyed themselves. We were told that some of the people occasionally go out to have coffee but it was said by some that they would like to go out more and would like more Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 15 activities. ‘Service user’s satisfaction questionnaire’ read said that there are ‘not enough activities could do better’. We were told that the home has their own transport which included a people carrier, and a Skoda car. But we were told that they had two permanent staff who had a driving licence to drive a car. It was said that the staff could not take people out for the day if the weather was good at weekends. This was due to not having enough car drivers to drive the car. The AQAA says the home is ‘to continue to build on our partnership with the rock club. To develop relationships with other organisations to increase the range of social activities offered to service users to develop friendships and relationships with others’. The manager was looking into people getting involved with the gardening project with Workbridge centre. We were told that the home had a quiz night once a week and people from another came to this. The home has a new pool table situated in the big lounge and the people were observed playing this game. We were told that some people go to the park, rock club, shopping, cinema, and they play bingo in the home. We were told that the home buys newspapers in different languages to meet the needs of the people from a different ethnic back ground. We were also told that a few people were looking at doing horse riding. A sail mobility activity was also coming up for the people to try out and this was a 4 day event. One person told us that that go to headways centre and enjoy this once a week for a few hours. We were told that the hairdresser visited the home every six weeks to cut people’s hair. The contract says that the people are offered a 7 day holiday per year as part of their contract fee. One person told us that they had been on holiday with a staff member supporting them. We were told that some people do not want to go on holiday so they go on day trips out. One person told us that they went on holiday with their family and enjoyed this. We were told that the people choose the menus with staff on a Sunday. A menu board was displayed for each day. We were told that the home does not have a cook but the staff do the cooking at the home. We observed the preparation of lunch, which was presented very well and the people were observed enjoying their meal. The staff were observed helping out in a kind manner. A variety of comments were received about the food that was offered to the people. One person told us that they had lived at the home for 3 years and told us ‘I like it here’ and the ‘food is nice with choices’. Another person told us that that ‘I do not like curry so I have fish and chips and I like this’. All the people spoken to said that the food at the home was very nice and they had Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 16 choices. We were also told that the home provides food that meets the needs of people from different ethnic back grounds. The home has a dining room, which has a table for 4 people to sit on and there are two dining tables for 8 people to sit on in the conservatory. At present the spaces for sitting at the table is meeting the needs of the people and staff on duty. However when the home has 14 people in the home, this will need looking at to ensure the people’s needs are met. The people told us that they liked their bedroom, and each persons bedroom seen was individualised to their taste. Most of the people in the home maintain contact with their families and friends and some go home for weekend visits. The manager recently had a peoples meeting and the views of the people were asked when a new person was being admitted to the home. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people’s health care needs are being met. EVIDENCE: We observed staff interaction and noticed that they talked to people in a respectful manner. The people we spoke to informed us that the staff knocked on their doors before entering their room. This was observed on the day of the inspection. People spoken to tell us that they ‘take a shower every morning’ and those people who needed help with personal care were supported by staff. We were told that the ‘staff are nice and helpful’. Some people bought their own clothes and one person told us that their family choose their clothes and they preferred this. Evidence in the care plans showed that people are offered support for their physical and emotional health needs. There were records of district nurses, Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 18 general practitioner, psychologist, and hospital appointments, and people have access to the opticians, dentists, chiropodist, and other health care professionals. The people told us that if they did not feel well, they would tell the staff. This was observed on the day of the inspection when one of the people told the manager that they were not feeling well. The manager called the doctor straight away. It was also said that staff accompany the people to appointments. The AQAA says that their future improvement plans is to ‘to provide more information to service users about health care risks’. We were told that the staff who gave out medication had received the accredited training. There were medication profiles for each person. The medication records looked at showed that there were no gaps in the record. The home had ordered the controlled drugs cupboard two weeks ago. The records and medication checked was satisfactory. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff have good understanding of the peoples behaviours to ensure they are protected from any potential abuse EVIDENCE: The home has a complaints policy, and the procedures for making a complaint is recorded in the statement of Purpose. We are told that the home has not received any complaints since 2005. All the people spoken to were capable of informing staff if they had any concerns. They told us that they would tell the manager, family, staff, key worker, if they had any concerns. This was also stated in the two ‘service user satisfaction questionnaire’ seen. The staff spoken to also told us that all the people were able to tell staff of any concerns verbally and person who did not say much was able to write this information down. All the staff had completed the safe guarding of vulnerable adults training. The staff spoken to informed us that they had completed this training. They had good understanding of this and understood the people’s behaviours to know if they were unhappy or not feeling well. The home has made safe guarding Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 20 referrals to the Social Services safe guarding team. The home had undertaken appropriate action in sorting out the situation. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and has a homely atmosphere to meet the peoples needs EVIDENCE: A tour of the home showed that the place is clean and homely. There is no smoking in the home. The colour scheme in the home was very pleasant and provided a relaxing atmosphere. This was confirmed by the people and staff spoken to at the inspection. The bedrooms seen were individualised to the people and all had en suite facilities. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 22 The people spoken to tell us that they like their rooms and some enjoyed spending time in them. The home had a new lounge and a sink at one side so the people are able to get a drink of water. This room had a pool table and a large TV and was pleasantly decorated. Another lounge was used as a quiet room and was pleasantly decorated with comfortable chairs. The kitchen was small but at present this was meeting the needs of the people. We were told by the managers that the kitchen was going to be re modernised and they were aware that once the occupancy level is full, the kitchen was not big enough to meet the people’s needs. Some of the cutlery was kept in the pantry. The conservatory was used as a dinning room and had the view of the garden. (See activities section) Because the work men were working on a room next door to the conservatory, the door to the conservatory on that side had to be closed for keeping the people safe. The room was hot because only one door and window were open. We were told that a build in fan was being put in this room. The home had one of these fans in the rear lounge. The people told us that they enjoy sitting in the garden. There was a patio area and a barbecue area. We were told that they would like nice table and chairs and an umbrella for them to sit on. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35,36 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. EVIDENCE: The staff recruitment files were looked at in detail. Evidence showed that the relevant information was being obtained to safe guard people from any potential harm. New staff undertakes the skills in care induction. Staff spoken to said that they received an induction at the home when they start work. Staff spoken to informed us that they were getting supervision every 4 to 6 weeks. The home did not use agency staff and we were told that there was enough staff on duty. We were told that the home retains a lot of their staff and this provides continuity to the people. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 24 The staff say that they enjoy working at the home, and it was said that they looked after the peoples needs well. We were told that they do lots of training and have completed all the statutory training. One staff said they enjoyed working at the home and with the people. It was said that they all get on well as a team. We are told that staff have meetings and it was said that there was one booked for July 09, but it was said that more meetings were needed on a regular basis. The AQAA states that the home has 14 permanent care staff and 4 bank staff. 8 people have NVQ level 2 or above training and the rest of the staff were completing this training in care. There was training schedule for 2009 and included both in house and statutory training. We were told that the manager is good by staff and ‘I do ‘enjoy working here, I like the guys, and staff’. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 25 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): 37,38, 39, 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in the best interest of the people. EVIDENCE: The new manager of the home was appointed on the 23rd of March 09. The manager was a State Enrolled Nurse (SEN) in mental health Nurse. We are told that she is a Manual Handling Trainer and Mental Capacity Act Trainer and she has many years experience in all areas of management. The manager informed us that she has applied to CQC to become the registered manager of the home. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 26 We are told that the manager has an open door policy. The staff tell us that the manager is ‘good’ and ‘very supportive’ and ‘encouraging’ and the ‘place had a nice atmosphere to work at’. The people living in the home also liked the manager and said that she was good. The accident and incident records show that these were being recorded appropriately and reported to the appropriate agencies. The home had recently sent out ‘service user’s satisfaction questionnaire’ and had two returned and they were waiting for the rest of the forms to come back. Very positive remarks were made about the people’s rooms, staff and the food. The home should also undertake staff, the people’s family, and other professional’s involved with the home surveys to find out their views on how the people’s needs are being met. The information recorded in the AQAA about ‘what we do well’ and ‘what we could do better’ and ‘how we have improved’ needs to be more detailed to explain the information on how the home is doing this. The fire alarm system was being tested on a weekly basis. The emergency lighting was done on a monthly basis. We were told that fire drill practice was also happening on a regular basis and the people were involved in this process. We were told by staff that they had received fire training and food hygiene training. The Environmental health officer had visited and awarded the home three stars on the 18th of July 08, which is good. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 27 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 2 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 3 25 4 26 4 27 x 28 X 29 X 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 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 2 X x 3 x Version 5.2 Page 28 Boughton Green Road DS0000012714.V376474.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 All the people must be provided the opportunity to be involved in drawing up their care plans and to ensure that they are signed by them or their representative. This is so they know how their goals and aspirations will be met. Timescale for action 30/10/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA12 YA33 Good Practice Recommendations Provide more activities to meet all the people’s needs. The information recorded in the AQAA about ‘what we do well’ and ‘what we could do better’ and ‘how we have improved’ needs to be more detailed to explain the information on how the home is doing this. Boughton Green Road DS0000012714.V376474.R01.S.doc Version 5.2 Page 29 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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