Care Home: Tomlen

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What the care home does well People live in spacious accommodation which they have helped to personalise to reflect their lifestyles and interests. One person said they had put lots of football memorabilia in their room and another said they had talked to staff about displaying photographs in communal areas. People said they liked going out to play pool, the cinema and had planned a holiday. One person enjoyed going to work in a garden centre. People had been involved in the choice of meals and one person said they liked to help baking cakes. Staff have access to a robust training programme and 80% of staff have a National Vocational Qualification. What has improved since the last inspection? This is a new service.TomlenDS0000073003.V375719.R01.S.docVersion 5.2 What the care home could do better: No requirements were issued at this inspection but some good practice guidelines were made. People`s religious preferences should be recorded. Each person should have an inventory for their personal fixtures and fittings. Some records use photographs and pictures alongside text. Other records might be more accessible to people if they were produced in this way. Key inspection report CARE HOME ADULTS 18-65 Tomlen 33 Streamside Tuffley Gloucester GL4 0TA Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 9th June 2009 10:00 Tomlen DS0000073003.V375719.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. Tomlen DS0000073003.V375719.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 Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tomlen Address 33 Streamside Tuffley Gloucester GL4 0TA 01452 528264 01452 528264 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) Cardell Care Limited Mrs Della Gilby Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Tomlen DS0000073003.V375719.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 either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) 2. Mental disorder (Code MD) The maximum number of service users who may be accommodated is 4. Date of last inspection New Service Brief Description of the Service: Tomlen is a small residential care home in Tuffley, Gloucester owned by Cardell Care which owns another home in Gloucester. It is close to local facilities and services and provides each person with their own room with en suite facilities. Three rooms have showers in their en suites and one room has access to a bath/shower room on the floor below. People share communal areas which include a kitchen/dining room, lounge and additional lounge/dining room. There are large gardens to the rear of the home. A people carrier and car have been provided for people’s use. Each person had a copy of the Statement of Purpose and Service User Guides which were also displayed in the entrance hall. Base fees for the home start at £1,094. Additional costs include a contribution towards transport and a television licence where people have one in their room. Tomlen DS0000073003.V375719.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 stars. This means the people who use this service experience good quality outcomes. This inspection took place in June 2009 by one inspector and included a visit to the home on 9th June. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing satisfactory information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). Surveys were returned from 2 people living in the home, 4 staff and health care professionals. We (the Care Quality Commission, CQC) talked to 3 people using the service, and asked staff about those peoples needs. We also looked at their care plans, medical records and daily notes. This is called case tracking. We looked at a range of other records including staff files, health and safety records and quality assurance systems. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? This is a new service. Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 6 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. Tomlen DS0000073003.V375719.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 Tomlen DS0000073003.V375719.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): 2, 3, 4 and 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. People have access to the information they need enabling them to make a decision about whether they wish to live at the home. A comprehensive assessment of the person’s wishes and needs are taken into consideration before offering them a place. EVIDENCE: Tomlen opened in January 2009 and since then three people have moved into the home. The home was initially registered for three people but has since increased its registration to four. One person transferred from another home owned by Cardell. They said they had visited the home and met with the other person moving in at the same time. They said they were glad that they had moved into Tomlen. Individual records did not provide information about when people had moved into the home. The other two people had moved into the home after a full assessment of need had been completed by the management of the home. The AQAA stated that the admission process can take up to several months when managers will meet Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 9 with people in their current accommodation to build up “a clear picture of the individual”. People were being encouraged to visit the home “on many occasions, having meals, meeting with staff and bringing their family with them.” The AQAA indicated that people were only admitted if they can meet their needs. Records confirmed that transition meetings had been held for two people moving into the home in a multi disciplinary forum. Each person had a three/four month review to assess whether the home was able to meet their needs. Copies of contracts with the placing authority were on their files and their individualised terms and conditions with the home had been given to each person, copies of which were kept electronically in the home. Tomlen DS0000073003.V375719.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 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are being involved in developing their care plans that reflect their aspirations and needs. Risks are being managed safeguarding them from possible harm. EVIDENCE: We looked at the care plans and other records for three people living in the home. The AQAA stated that “we plan the individual’s care with them and not for them.” People confirmed they had been involved in this process and they had signed some documents. Care plans reflected people’s assessed needs as identified in their placing authority assessments and care plans. Where changes had occurred it was evident that care plans were being adjusted or new plans developed. Care plans were holistic and had been developed for people’s physical, intellectual, social and emotional needs. People’s assessed needs were identified alongside how they were going to be met and short term Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 11 and long term goals. These provided staff with clear information and conversations with them indicated that they had a good understanding of the support people required. Plans could be produced in a format using plain English and illustrated with pictures, symbol or photographs to make them more accessible to people living in the home. The review format used by the home made good use of photographs to illustrate the text showing people’s likes, dislikes, goals and wishes. Surveys indicated that a person centred approach was in place and that the home advocated appropriately for people. Each person had a communication care plan in place providing details of their preferred mode of communication. One person had used Makaton sign language and a story book but staff said that since moving into the home their verbal expression had increased and they had opted not to use these communication methods. Staff had completed training in Makaton and the manager was doing a British sign language course. All three people were observed communicating positively with staff, expressing their needs verbally and understanding responses from staff. The AQAA stated, “Individuals make choices about their lives in every aspect, every day, our daily notes are used well to reflect this.” One person’s care plan indicated that they were to be offered no more than two choices because any more than this would lead to confusion and anxiety. Daily records confirmed this. Daily notes reflected how people’s needs were being met and made reference to other monitoring forms used such as ABC charts and body maps. Risk assessments had been developed from hazards identified in care plans which clearly identified when risk assessments were in place. These enabled people to take risks in a managed way attempting to reduce known hazards. People had expressed concern about the use of the home’s car. Risk assessments indicated that for one person there were possible risks associated with the use of transport. A people carrier was purchased with a view to minimising this. This indicated that the management of the home were very responsive both to the views of the people living there and to safeguarding people from possible harm. Each person had a ‘Thumb sketch’ providing an overview of their personal details and a photograph. This was laminated and provided essential information that might be used if the person was missing. Tomlen DS0000073003.V375719.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: 11, 12, 13, 14, 15, 16 and 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. People who use the service are able to take part in appropriate activities inside and outside of the home, have links with the local community and pursue a range of leisure interests in order to enhance their lifestyle. People’s rights are respected and they are supported to take responsibility for aspects of the running of the home, helping them to feel valued and included. EVIDENCE: People’s religious or spiritual preferences were not recorded in care plans although their health action plans made some reference to this. One person goes to a church social and staff said that people do not wish to follow any religious or spiritual beliefs. Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 13 One person who had previously attended a local college was being supported to complete this course. Other people had joined them at this college and said they had already registered for courses in the new college year. On the day of our visit all three people had been to college. There was evidence in daily reports and other records that one person had struggled with going to college and had been supported to make decisions about when they wished to attend. They had settled on reducing the number of days at college but it was evident that if they did not want to go to college staff respected this decision. Staff were however checking with them several times in case they changed their mind. On occasion this has happened. One person said they were working one day a week at a local nursery. They showed us pictures of the work they were doing and friends they had made there. The AQAA stated that the home would be making links with local employers over the next year to support people to find work if they wish. People use the home’s transport as well as public transport. People said that they had been supported in a variety of activities and leisure pursuits including bowling, pool, cinema, day trips, pub and social clubs, theatre and garden centres. People said they liked to play games and do some art, baking or gardening when at home. One person said they had their own space in their room to watch television or listen to music if they wished to be alone. People were planning a holiday to the Isle of White. One person had been there to do Special Olympics and had requested revisiting the island. Surveys confirmed that people had “a good variety of life, including great educational options and life skills.” People said they had regular house meetings and minutes of these were kept in the office. These evidenced how people were involved in making decisions about their lifestyle – what they would like to do and their choices for the weekly menu. People were observed making decisions about what they would like to do and being supported to achieve this. For instance, one person wanted to telephone their family to arrange a visit for the following day and this was done. One person said they had been supported to visit their family for the weekend. Other people were visited at the home. People were also being helped to maintain contact with friends. One person said they kept their room clean and another said they shared a vacuum cleaner. Another person liked to bake cakes and people were observed helping themselves to drinks and snacks. One person had their own cupboard to store their personal snacks. Menus indicated that freshly produced meals were provided for people with alternatives being offered where appropriate. The menu was produced in a format using photographs of people and their choice of meal for the week. On the day of our visit people had a choice of baked potatoes and salad with either chicken or prawns. They said it was lovely. One person had gluten and diary free diet and the menu took this into account. There was a large stock of foodstuffs especially for them. Tomlen DS0000073003.V375719.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 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the handling of medication and training of staff in specialised techniques. EVIDENCE: The way in which people liked to be supported with their personal care was clearly recorded in care plans and other records. Each person had listed their likes and dislikes in their ‘Thumb sketch’. Where people had a preference about the gender of staff providing their personal care this was noted in their care plan. Daily records indicated that there was flexibility in daily routines reflecting people’s wishes and needs. Where people needed regular support from a Community Psychiatric Nurse it was evident that the care programme approach was in place with regular contact and reviews. Likewise people were having support from health care professionals including a Psychiatrist and Speech and Language Therapist. The Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 15 manager stated that the home would contact the local Community Learning Disability Team for support when needed. Surveys from health care professionals indicated that the home related well with them. Each person had a health action plan in place providing information about their medication and health care needs. Records of appointments with a range of health care professionals were kept with a record of the outcome of each appointment. These confirmed that people were having access to regular appointments with their Doctor, Dentist and Optician. Systems for the administration of medication were examined and found to be satisfactory. Each person had given their consent for medication to be administered and had an individual profile in place. A monitored dosage system was in place and records were being maintained correctly. Stock levels were recorded on boxed medication and on the Medication Administration record. All items had been labelled with the date of opening. Staff had received training from the pharmacy as well as completing an open learning course in the safe handling of medication. They had also received training in the administration of Buccal Midazolam. The temperature of the medication cabinet was being recorded. The home had a copy of the most recent British National Formula. Tomlen DS0000073003.V375719.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 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to enable people to express their concerns and they are confident that they will be listened to. People should be safeguarded from possible harm or abuse. EVIDENCE: The home had a complaints procedure which had also been developed in a format using text and pictures. This was displayed in the hall of the home. People said that if they had concerns they would talk to the manager or staff. They had also discussed concerns at a house meeting and these were recorded and responded to. A complaints/compliments folder had been set up which contained a copy of a compliment. The DataSet indicated that the home had not received any complaints and this was confirmed during our visit. Staff had completed training in the protection of adults and those spoken with had a good understanding of what they should look for and how to report suspected abuse. There was information in the office about local procedures. Staff confirmed that they had completed training in the management of challenging behaviour and that new staff completed this training as part of their induction. Behaviour care plans indicated how staff should support people when they were anxious or angry. Triggers were identified and guidance about how to divert and distract people. Staff spoken with had a good understanding Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 17 of how to support people and confirmed that they had not used physical intervention apart from guiding people. They said that diversion and distraction had been used effectively. Any incidents were recorded on ABC (Antecedent, Behaviour and Consequence) charts. There were formats in place for the recording of the use of physical intervention. Staff confirmed their understanding that we would be notified under Regulation 37 about the use of physical intervention. People were being supported to manage their own finances. They had chosen to keep their personal money in their room in secure facilities. They were keeping a record of expenditure with the help of staff and their were regular checks on balances. Tomlen DS0000073003.V375719.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 and 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. People live in comfortable, spacious and safe accommodation which they are helping to adapt to reflect their interests and lifestyles. EVIDENCE: Tomlen provides spacious and modern accommodation for 4 people over three storeys. Two people share the top floor and have spacious bedrooms with en suites. One person uses a bathroom on the floor below. All bedrooms have space for a sofa to watch television and one person has access to a separate living room. Communal areas were pleasantly decorated and fitted out with good fixtures and fittings. One person said that these looked quite bare but that they had been chatting with staff about collecting some photographs to put on walls. The manager said that communal areas would be personalised as people settled into the home. Inventories had not been put in place for people. Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 19 A person was employed for general day to day maintenance and long term plans for the home included adding a conservatory to the rear of the house. There are large grounds to the rear of the property and a gardener is employed to maintain the lawn. At the time of the visit the home was clean and tidy. The laundry was situated next to the office which is in a separate building. A sink for hand washing and liquid soap/paper towels had been provided. Hazardous products were stored in this area. The home had recently had an environmental health inspection and was awarded five stars. Tomlen DS0000073003.V375719.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 and 35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. People should be safeguarded from harm by the recruitment and selection procedures which are in place. EVIDENCE: Some staff had transferred from another home owned by Cardell Care and a number of new staff were appointed to make up the team. This has provided a staff team with a mix of skills and experiences. New staff spoke positively about the support they had received from experienced staff and of their induction. The home provides an in house induction alongside the Learning Disability Qualification which provides them with access to mandatory training and learning disability/autism awareness. The manager confirmed that new staff had been registered to complete this qualification. The DataSet indicated Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 21 that 80 of staff had a National Vocational Qualification (NVQ) in Health and Social Care. The recruitment and selection files were examined for three new members of staff. It was not evident from the information on these when they started working in the home. Each person had supplied an application form with a full employment history. There were gaps in the history for one person which had not been explored but there was evidence that this had been done for other staff. Staff were not starting work until a satisfactory Criminal Records Bureau (CRB) check and Povafirst check had been completed. Two satisfactory references were in place and there was evidence that a verbal enquiry had been made to verify one of these. Where needed a third reference had been provided to confirm the reason why staff had left former employment in care. There was proof of identity in the form of driving licences. The manager stated that other proof of identity had been seen when staff applied for CRB checks. Copies of training certificates from former employment were in place for most people. The manager stated that a training matrix was being developed but was not seen at this inspection. Staff confirmed access to a range of training courses and open learning packages including specialist training in learning disability, epilepsy, mental health and autism. Tomlen DS0000073003.V375719.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 and 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect. Effective quality assurance systems will be in place that involve people who live at the home. Satisfactory health and safety systems are in place which should ensure a safe environment. EVIDENCE: The manager had considerable experience supporting people with mental health issues and learning disabilities. She had a NVQ Level 4 in Health and Social Care and Registered Managers Award. She had just completed a degree and would like to complete a Postgraduate Diploma in Autism Spectrum. Staff said that she had excellent management skills and as a lead practitioner they Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 23 felt very supported by her. She had completed The Annual Quality Assurance Assessment (AQAA) as part of the inspection which provided information about how the service had been set up involving people living there and plans for future development. The manager had completed training in the Mental Capacity Act and Deprivation of Liberty and said they had cascaded information to staff. Staff were registered to complete this training with the local county council. There was information in the home about this legislation and a policy had been put in place. The home has no restrictions in place and no one living there is subject to the Deprivation of Liberty safeguards. The manager said that a quality assurance system was being developed in line with the system used in their other home. This will involve feedback from people living in the home and other significant people. A newsletter will be produced twice a year inviting feedback. An annual development plan would be produced from these and other auditing systems in place. Monthly visits to the home take place by the Responsible Individual and there is close contact between the two homes. Regulation 26 reports were seen to be in place. A monthly audit was also in place for health and safety systems around the home. Records for the monitoring of fire systems, fridges and freezers and water temperatures were in place and taking place at appropriate intervals. Good food hygiene practice was observed to be in place, with items labelled in the fridge with date of opening or production and the temperatures recorded for hot meals. A fire risk assessment was in place and an evacuation procedure displayed. Systems were in place to ensure the servicing of equipment and utilities. Staff had completed training in moving and handling, fire, first aid and food hygiene. Environmental risk assessments were in place. Tomlen DS0000073003.V375719.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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 25 Tomlen DS0000073003.V375719.R01.S.doc NA 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. 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. 2. 3. 4. 5. Refer to Standard YA5 YA6 YA11 YA24 YA34 Good Practice Recommendations The date of admission to the home should be recorded. Consider illustrating care plans with symbol, picture or photograph. A record should be kept of people’s religious or spiritual preferences, this includes when they have no particular beliefs. An inventory should be put in place for each person detailing their personal possessions. Consider using a front sheet to provide evidence of staff start date and that proof of identity has been seen. Tomlen DS0000073003.V375719.R01.S.doc Version 5.2 Page 26 Care Quality Commission South West 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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