Care Home: Thingwall Lane, 28

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What the care home does well The service has produced good information about the home, which is given out to people who are thinking about moving in. Strict procedures were in place for assessing and admitting new residents so they can be sure it is the right place for them to live. Good care plans were in place, which the resident helped put together. The plans, which have been regularly reviewed and up dated provide staff with all the information they need so that they can support the resident in the right way. The residents health and personal care needs were well recorded, supported and monitored to ensure they stay well. The resident has been given lots of opportunities for to take part in the things they like to do both at home and in the local community. Procedures at the home make sure that residents are protected from abuse or neglect. The home is clean and tidy and free from hazards making it a pleasant and Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 safe place for residents to live. The home is well run in the best interests of the resident and staff. What has improved since the last inspection? Staff have received training, which they need to meet the needs of the resident. Each member of staff now has a training and development plan identifying future training needs. The walls and woodwork in the kitchen have been painted. What the care home could do better: The bathroom floor and the grouting on the wall tiles must be replaced to ensure the comfort and dignity of the resident. The electricity system must be checked by an approved electrician at the recommended times and an up to date certificate of safety obtained and kept at the home to show that the system is safe and in good working order. Policies and procedures should be reviewed and were necessary updated on a more regular basis. This is so that staff, residents and their representatives have accurate and up to date information about their health safety and welfare. Key inspection report CARE HOME ADULTS 18-65 Thingwall Lane, 28 28 Thingwall Lane Liverpool Merseyside L14 7NX Lead Inspector Janet Marshall Unannounced Inspection 26th March 2009 10:00 Thingwall Lane, 28 DS0000021487.V374939.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. Thingwall Lane, 28 DS0000021487.V374939.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 Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thingwall Lane, 28 Address 28 Thingwall Lane Liverpool Merseyside L14 7NX 0151-228-0824 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.c-i-c.co.uk. Community Integrated Care Miss Suzanne Walton Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to Include up to 2 (LD) The service should at all times have a suitably qualified and experienced manager who has been approved by the Commission for Social Care Inspection 20th September 2006 Date of last inspection Brief Description of the Service: 28 Thingwall Lane is operated by C.I.C. Maritime Housing own the building and act in the capacity of Landlord. The service is registered by the Commission to provide support and care to two residents with a learning disability. At the time of the inspection visit there was one resident living at the home. The home is situated on the border of the borough of Knowsley and Liverpool. It is within easy reach of local shops, pubs and community health centres and is close to public transport links. The home is a large detached property and fits in well to the surrounding community. The fees for the home are £325 per week. Thingwall Lane, 28 DS0000021487.V374939.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 living at the home experience good outcomes. This was a key inspection. A key inspection is a planned inspection of the service and the report is put together using information gathered in a number of different ways to help us decide how good the service is. We keep all information we receive about the home in a file, we looked at all the information we have received since the last inspection. We sent out a form to the home called an Annual Quality Assurance Assessment (AQAA). The AQAA has to be filled in and returned to us by a set date usually before the site visit takes place. The AQAA was filled in and returned to us on time and provided us with all the information we asked for about the home. We carried out an unannounced visit to the home, this is when we visit with out any body knowing and is called the site visit. The manager and a support worker were on duty at the time of the site visit and discussions took place with them both. Due to certain limitations the resident was unable to comment about their experiences at the home, but they were case tracked. This is a process we use to find out whether residents are receiving good quality care that meets their individual needs. It is done by talking to people, looking at results of surveys and reading the records of a sample of people that live at the home to give us a good idea of what it is like for them. Also during the site visit a selection of other records and certificates, which have to be kept in the home by law were looked at and checked to make sure they were up to date and accurate. What the service does well: The service has produced good information about the home, which is given out to people who are thinking about moving in. Strict procedures were in place for assessing and admitting new residents so they can be sure it is the right place for them to live. Good care plans were in place, which the resident helped put together. The plans, which have been regularly reviewed and up dated provide staff with all the information they need so that they can support the resident in the right way. The residents health and personal care needs were well recorded, supported and monitored to ensure they stay well. The resident has been given lots of opportunities for to take part in the things they like to do both at home and in the local community. Procedures at the home make sure that residents are protected from abuse or neglect. The home is clean and tidy and free from hazards making it a pleasant and Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 6 safe place for residents to live. The home is well run in the best interests of the resident and staff. 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. Thingwall Lane, 28 DS0000021487.V374939.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 Thingwall Lane, 28 DS0000021487.V374939.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): 1 & 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given good information about the home and their needs are assessed before a decision about them moving is made, so that they can be sure it is the right place for them to live. EVIDENCE: The AQAA and discussion with the manager showed that there have been no new residents admitted to the home since the last inspection. One resident has moved out because their needs could no longer be met at the home. Discussion with the manager showed that the move was well planned and supported by staff at the home. The manager clearly described the processes that she would follow for assessing and admitting a new resident to the home. This included giving people information about the home such as the Statement of Purpose and a Service user Guide. Both documents, which were looked at, included all the information that people need to know about the home. They also provided other information such as details of the staff team, emergency procedures and the arrangements made for dealing with complaints. Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 9 The manager would then carry out a full assessment of the prospective residents needs involving them, their families and other people such as social workers and nurses. The needs assessment document used by the service covers things such as communication, family/social contact, health and personal care and risk management. Once completed the assessment is used to help decide if the persons needs can be met at the home. If they can and the person chooses to live there they would then be offered a planned and staged move to the home including short visits to meet other residents and staff and overnight stays. Thingwall Lane, 28 DS0000021487.V374939.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): 6, 7 & 9. 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. Staff have all the information they need to meet the residents needs and to support them to make choices and decisions as part of an independent lifestyle. EVIDENCE: The resident had a number of different types of care plans covering in detail all their care and support needs. All parts of the residents care plan were looked at in detail as part of the case tracking process. They covered all their care and support needs such as personal and health care, independent living skills, accessing the community, relationships and financial needs. The plans were person centred and covered in detail things what is important to the person, what they are good at doing, what they like and dislike, what Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 11 they need help with and what they want to happen with their lives. The person centred care planning approach enables people to have more choice and control over their own lives. The manager said all staff have completed training in person centred planning. Review records, which were in place showed that care plans have been regularly reviewed and updated involving the resident and important people in their lives such as their family, the manager and staff at the home. A member of staff spoken with said the residents care plan always provides them with up to date information about the needs of the person they support. Care records and discussion with the manager showed that communication profiles and diaries are an important part of the persons care plan have been developed and are used to support them to make every day decisions and life choices such as what to eat and were to go. During the inspection visit staff were seen communicating effectively with the resident. A member of staff spoken with showed a really good understanding of how to ensure the residents rights are promoted and how limitations are only put in place for their safety and welfare. Information in the care file and discussion with the manager showed that independent advocates would be consulted when necessary. The resident is encouraged to take responsible risks, a range of risk assessments, which have been carried out, ensure their independence is promoted and they are protected from the risk of harm. The assessments clearly described the action that staff must take to minimise risk of accidents happening to the resident and themselves. A selection of risk assessments were viewed and showed that they are reviewed and updated at regular intervals. Thingwall Lane, 28 DS0000021487.V374939.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: 12, 13, 15, 16 & 17. 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 resident is given lots of social and leisure opportunities and eats well as part of an active and healthy lifestyle. EVIDENCE: The AQAA showed the residents social care needs have been assessed and they are offered a wide range of activities inside and outside the home, which meet their needs and promote their personal development. An Activity programme was in place for the resident, daily records showed that the programme is very well supported and followed. The resident has their own vehicle, which is driven by staff to help them get out and about. As well as recreational and leisure activities the resident is also encouraged and supported to help with small tasks around the house such as cleaning their Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 13 bedrooms, laundering their clothes polishing and shopping for personal items and food. On the day of the visit staff were seen encouraging and appropriately supporting the resident with some of these tasks. The resident has keys to their own bedroom and the front door and appropriate measures are in place so that they are able to use them safely and independently. Daily records showed that the resident is encouraged to maintain contact with family and friends and personal relationships are respected and appropriately supported by staff at the home. Menus, which where viewed at the home showed a variety of healthy meals. The manager said that menus are often changed at the residents request. A member of staff showed a good awareness of the importance of nutritious and balanced diets. Staff were observed offering the resident drinks and snacks. Care plans included information about resident’s likes and dislikes with regard to food. A good stock of fresh, frozen and tinned food was seen at the home. There were also sufficient crockery, cutlery pots and pans, which were of good quality. There was a fridge, freezer and microwave, which were all of a domestic style and in good condition. The manager confirmed the resident is always involved in the main weekly shop for food as well as shopping daily for essentials such as fresh bread and milk. Thingwall Lane, 28 DS0000021487.V374939.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): 18, 19 & 20. 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 residents health and personal care needs are well supported and understood by staff to make sure they stay physically and emotionally well. EVIDENCE: The residents care plan detailed information about the type and level of support they need with personal care as well as their preferred routines. Health action plans, which were part of the persons plan of care, covered in detail their healthcare, needs and the support that they need to stay well. Records within this section showed that they are offered minimum annual health checks. As well as visits to primary healthcare services such as dentist, opticians and doctors the resident is also supported when necessary to attend specialist services. Records detailing the visits were available in good detail as was information about specialist health care appointments. Where appropriate visits to the home by healthcare professionals are arranged and recorded. Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 15 Communication profiles show how the person communicates if they are in pain or unwell and the action staff should take in response. During the inspection visit staff were observed assisting the resident in a gentle and polite way. Through discussion staff showed that they understood the importance of ensuring residents privacy and dignity a staff member said, said, “I always knock on doors before entering”. During this inspection visit all medication and medication administration records were examined. Medication and records were stored in a locked cabinet. Discussion with staff and examination of records showed that staff have completed medication awareness training. A policy for the safe handling and administration of medication was availble at the home. The manager showed a good awareness of the homes medication polices and procedures. Thingwall Lane, 28 DS0000021487.V374939.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): 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. Procedures and practices followed at the home ensure that people can confidently complain and are protected from abuse, harm or neglect. EVIDENCE: The AQAA told us that there have been no complaints made at the home in the last year. The Commission has received no complaints regarding the service since the last inspection. There was a complaints procedure on display at the home. There was also a complaints book to record any complaints made at the home. The Service User Guide and the homes Statement of Purpose also included a summary of the homes complaints procedure. It was not possible to assess the residents understanding of the complaints procedure due to their limited understanding. The manager did however state that resident’s representatives have received a copy of the procedure. A member of staff spoken with said that they knew about the complaints procedure and would be confident about raising any concerns or complaints if they needed to. During discussion a member of staff showed a good awareness of what to do if they suspected or witnessed abuse. A Protection of Vulnerable Adults procedure was available at the home. Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 17 The AQAA told us that all staff have received Protection of vulnerable adults training. Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 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, 27 & 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 safe, but some repairs are needed to make it more comfortable. EVIDENCE: The home is a large semi detached house located in a popular residential area of Merseyside. It is in keeping with the local community and provides a comfortable and homely environment. There are gardens at the front, side and back of the house. A garage and driveway at the back of the house provides off road parking for several cars. A number of requirements were given as part of the last inspection report. This was because resident’s comfort and dignity was undermined by parts of the home, which were in poor condition. The AQAA showed the following improvements to the environment since the last inspection. • Redecoration of the kitchen, dining room, hall, stairs and landing • New leather sofas for the main lounge Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 19 • New dining table and chairs A requirement was given as part of the last inspection report for the floor and the grouting to the wall tiles in the bathroom to be replaced. This was because they were in poor condition and there was an unpleasant smell in the bathroom. They have not been replaced since the last inspection although attempts have been made to improve them. Both the flooring in the bathroom and the grouting were still in poor condition and there was still an unpleasant smell evident, so they must be replaced as previously required, to ensure the comfort and dignity of the resident. On the day of the inspection visit the resident was seen moving freely around the home. The resident’s bedrooms was attractively decorated and furnished to a good standard. It was warm, bright and well ventilated. The bedroom was personalised to suit the residents own tastes. All parts of the home were clean and tidy and there were no hazards identified. Laundry facilities are sited in a utility room separate to the kitchen, it was clean and equipped with washing and drying machines. The AQAA showed that the required policies and procedures for control of infection and cleaning routines are in place at the home. It also showed that soiled laundry is washed appropriately and clinical waste is disposed of in the correct way. The AQAA, discussion with staff and examination of records showed that staff have completed training in relation to infection control. Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 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): 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. The resident is supported by a competent and qualified staff team. EVIDENCE: The AQAA showed that strict staff recruitment procedures are in place and CIC is an equal opportunities employer that ensures issues of equality and diversity are thoroughly addressed during the interview process. Staff records, which were looked at during the visit and details provided in the AQAA showed that satisfactory recruitment checks have been carried out for all staff that work at the home. Examination of the staffing rota and details provided in the AQAA showed that there are four full time staff that work at the home and the team is made up of people of various age, gender and ethnicity. The manager said that there is one waking member of staff on duty each night and at least one member of staff on duty throughout the day and evening. Discussion with staff, information provided in the AQAA and records seen at the home showed that staff have completed a range of appropriate training Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 21 and a training programme for future training is now in place for each of them. This training covered a range of courses relating to the care and support of the resident and the efficient running of the home. For example first aid, health and safety, protection of vulnerable adults (POVA) and fire awareness. The AQAA showed most of the staff have an NVQ Level 2 or above in care and those that haven’t are working towards it. A member of staff spoken with during the visit confirmed the organisation provide a lot of training, which they are always encouraged to attend. Staff records, which were looked at during the inspection visit showed that staff have received induction training when they started work at the home. Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 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, 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 well managed to the benefit of the resident and staff. EVIDENCE: There has been no change to the management of the home since the last inspection. The manager Suzanne Walton is qualified and experienced to manage the service, she has a National Vocational Qualification level 4, and the Registered Managers Award, both recognised qualifications for a manager of a residential care service. The manager said she continues to undertaken periodic training to update her knowledge and skills whilst managing the home. A member of staff said, “The manager is very good, she is approachable and understanding” Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 23 Systems are in place to ensure the ongoing monitoring and improvement of the service. This includes supervising staff, reviewing administrative procedures and reviewing the residents care plans to ensure their care need requirements are being met at the home. A manager within the company carries out regular audits of the homes systems and procedures to make sure the home is running properly and in the best interests of the resident. The AQAA also showed that all other policies, procedures and codes of good practice, which are required for this type of service, are available at the home. However, details in the AQAA showed that some of them have not been reviewed for over ten years. It is recommended as part of this report that policies and procedures be reviewed and were necessary updated on a more regular basis. This is so that staff, residents and their representatives have accurate and up to date information about their health safety and welfare. The AQAA told us that equipment used at the home has been serviced or tested as recommended by the manufacturer or other regulatory body and all the required checks have been regularly carried out on equipment used at the home. They include electrical circuits, portable electrical equipment, heating system and gas appliances. However A selection of certificates and records, which were seen, supported this information. The electricity certificate was out of date. A service manager confirmed that arrangements had been made for an approved electrician to visit the home to carry out a check on the system. The electricity system must be checked by an approved electrician at the recommended times and an up to date certificate of safety obtained and kept at the home to show that the system is safe and in good working order. Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 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 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 1 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 x 3 x x 2 x Version 5.2 Page 25 Thingwall Lane, 28 DS0000021487.V374939.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 YA27 Regulation 23 16 Requirement The bathroom floor and the grouting on the wall tiles must be replaced to ensure the comfort and dignity of the resident. The electricity system must be checked by an approved electrician at the recommended times. An up to date certificate of safety must be obtained and kept at the home to show that the system is safe and in good working order. Timescale for action 26/06/09 2. YA42 23 26/05/09 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. Refer to Standard YA42 Good Practice Recommendations Policies and procedures should be reviewed and were necessary updated on a more regular basis. This is so that staff, residents and their representatives have accurate and up to date information about their health safety and welfare. DS0000021487.V374939.R01.S.doc Version 5.2 Page 26 Thingwall Lane, 28 Thingwall Lane, 28 DS0000021487.V374939.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission Unit 1 Tustin Court Port Way Preston PR2 2YQ 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. 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