Care Home: Trabel House

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What the care home does well Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 The home is well managed and run in the best interests of the people who live there. People are consulted about the way the home is run and their views are listened to and acted upon. There is information about the service in the `Service User Guide` people can visit the home before they move in so they can decide if it is the right place for them. Anyone who is thinking of moving into Trabel House is assessed before a place is offered. This makes sure that staff are able to provide the care and support people need. Everyone has an individual care plan that identifies people`s needs and what support staff need to offer to make sure those needs are met. The home is clean and comfortable. There are good quality assurance systems in place. This makes sure that the home is being managed properly and that the people living there can shape the service. We asked people living in the home and staff what the home does well. These are some of the comments we received: `There is a lot of communication and I think there is a lot of good team work that makes the house work so well. The staff that work here meet the needs of the service users well and there is always support there for staff if they need it.` `Staff listen to service users requests and wherever possible act on them.` `Trabel House has done well in providing high quality care for service users who live here. All service users are treated with respect and dignity and the staff team work together to pass important information on here relevant. The service users also have a say in the standard of care they receive on a regular basis. Service user meetings are held and people get the opportunity to say what they like and dislike and what changes they would like.` What has improved since the last inspection? The complaints procedure is on display where everyone can see it. More staff have completed their National Vocational Qualification training in care. This means that there are more staff that have been assessed as being competent to do their job.Trabel HouseDS0000026308.V377670.R01.S.docVersion 5.3The quality assurance systems have improved. This means that the company are always looking at ways to improve the service. What the care home could do better: Make sure there are enough staff on duty at all times. This will make sure that everyone gets the support they require. Make sure that the recruitment records that are kept in the home have the dates when all of the necessary checks were received. This will make sure that staff have been properly checked before they start working in the home. Make sure that all of the staff complete infection control and fire safety training. This will make sure that staff are working safely. Make sure that the area manager completes reports on her monthly visits. This will make sure that the manager knows if there is any action she needs to take or about any agreements that have been made. Key inspection report CARE HOME ADULTS 18-65 Trabel House 26-28 Cambridge Road Huddersfield West Yorkshire HD1 5BU Lead Inspector Paula McCloy Key Unannounced Inspection 18th September 2009 09:15 Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Trabel House Address 26-28 Cambridge Road Huddersfield West Yorkshire HD1 5BU 01484 535180 01484 420008 rm@valeoltd.com 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) Valeo Ltd Roslyn Maureen McGuire Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two service users can be accommodated at the Gate House. Date of last inspection 19th September 2007 Brief Description of the Service: Trabel House is a care home for 12 people with learning difficulties and associated challenging behaviours. Trabel House is in Huddersfield within walking distance of the town centre and is set in its own well-kept gardens. There are ten single bedrooms in the main house, a lounge, dining room, breakfast room, kitchen and laundry room. The Gate House, which is adjacent to Trabel House, is a two-bedroom bungalow with a lounge/dining room, kitchen, bathroom and store room. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars – good service. This means the people who use this service experience good quality outcomes. This inspection was carried out to assess the quality of care provided to people living at the home. The inspection process included looking at the information we have received about the home since the last key inspection as well as a visit to the home, which lasted approximately 5.45 hours. The manager completed the Annual Quality Assurance Assessment (AQAA) that we asked for. This gave us lots of information about the service. We have used some of this information in this report. During the visit we spoke to one person living in the home, 2 members of staff and the manager. We also observed staff delivering care, looked at various records and looked around the home. Surveys were sent to 10 people living in the home, 10 staff and 5 health care professionals; these cards provide an opportunity for people to share their views of the service with us. Information received in this way is shared with the home without identifying who has provided it. Five people using the service, ten members of staff and three health care professionals wrote to us with their comments. Their comments have been used in this report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 6 The home is well managed and run in the best interests of the people who live there. People are consulted about the way the home is run and their views are listened to and acted upon. There is information about the service in the Service User Guide people can visit the home before they move in so they can decide if it is the right place for them. Anyone who is thinking of moving into Trabel House is assessed before a place is offered. This makes sure that staff are able to provide the care and support people need. Everyone has an individual care plan that identifies peoples needs and what support staff need to offer to make sure those needs are met. The home is clean and comfortable. There are good quality assurance systems in place. This makes sure that the home is being managed properly and that the people living there can shape the service. We asked people living in the home and staff what the home does well. These are some of the comments we received: ‘There is a lot of communication and I think there is a lot of good team work that makes the house work so well. The staff that work here meet the needs of the service users well and there is always support there for staff if they need it.’ ‘Staff listen to service users requests and wherever possible act on them.’ ‘Trabel House has done well in providing high quality care for service users who live here. All service users are treated with respect and dignity and the staff team work together to pass important information on here relevant. The service users also have a say in the standard of care they receive on a regular basis. Service user meetings are held and people get the opportunity to say what they like and dislike and what changes they would like.’ What has improved since the last inspection? The complaints procedure is on display where everyone can see it. More staff have completed their National Vocational Qualification training in care. This means that there are more staff that have been assessed as being competent to do their job. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 7 The quality assurance systems have improved. This means that the company are always looking at ways to improve the service. 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. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 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. Individual needs are assessed before any decision is made about people moving in. People are provided with information about the service and invited to visit to see if it is the right place for them. EVIDENCE: There is a Statement of Purpose and Service User Guide available that contain a lot of information about the service. The Service User Guide is also available in an easy read style if people want the information presented in this way. Everyone is assessed before they move into the home to make sure that their needs can be met there. We looked at the records for two people and found good assessment information about people’s care needs. Staff told us that usually people visit the home before they move in, come for a meal and stay overnight as many times as they wish, so they can see for themselves if they like it. The person most recently admitted was unable to visit the home. Staff visited them fourteen times before they moved in and provided them with pictures of the home and talked about what the home had to offer. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 10 Staff told us that there is a lot of information available before people move in so that they know what care and support they will need to offer. This means that staff are sure they can meet peoples needs before they are offered a place at the home. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are encouraged and supported to make decisions about their lives and are involved in planning their care and support. EVIDENCE: In the annual quality assurance assessment (AQAA) the home told us everyone has a care plan that is regularly reviewed and updated by staff. People are encouraged to participate in updating their care plan. Staff ensure that personal preferences are clearly documented within the care plan and key workers are actively liaise with individuals to ensure all information on the care plans is accurate. We looked at care plan and risk assessment records for two people who live at the home. We found they gave clear information about peoples needs and the Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 12 action staff must take in order to meet those needs. There is evidence that the plans are reviewed and evaluated regularly to make sure they are still relevant for people, this makes sure they are still meeting peoples needs properly. The manager is aware that care plans need to continue to develop and is looking at using a more formal, recognised format for person centred planning. There are good clear plans in place that have been agreed with individuals about aspects of their care and support, for example the management of finances. This means that staff respond consistently and stick to the agreements that have been made with people. The daily records are of a reasonable standard, and give some account of the day to day support people receive. They do need to improve so that they accurately reflect the care and support that has been given so that it is clear to see if the care plan is effective. Everyone has an individual timetable of activities. For example: meals out, pub, shopping trip, hydrotherapy etc. Staff told us that people are getting out and about but because two members of staff always need to be in the main house to support one individual the more impromptu activities and outings have stopped. (See section on staffing). Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make choices about their lifestyle. EVIDENCE: People take part in a variety of activities of their choice. From talking to staff and looking at the care plans we found out that people are involved in the following: clubs, shopping, meals out, trips out, local events, etc. In the past people have attended college, but no one living at the home currently is doing any courses. The manager is aware that the day services people attend are specifically for people with learning disabilities. In the AQAA she told us that they will be investigating the possibility of people attending local support groups so that they can meet with other people who share their interest but not necessarily their disability. This would mean people would have the opportunity to make new friends and participate in the wider community. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 14 There are no care plans in place that identify people’s social, educational or occupational needs. These should be developed so that it is clear what action staff are taking to help people develop in these areas. People use the facilities that are available in the local community using public transport or the homes transport. People are also given the chance to enjoy their own company if this is what they prefer. People are given good support to keep in touch with family and friends. Some individuals stay with their families on a regular basis. People can also invite relatives and friends to their home if they want to. There is a weekly menu that is prepared in consultation with people living in the home and it incorporates their choices. Staff are aware of people’s particular likes and dislikes and make sure an alternative meal is available if people don’t want what is on the menu. People are encouraged to take part in the domestic routine of the home, for example, cooking meals and doing their own laundry and cleaning. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 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. Peoples general health care needs are well met and based upon their individual needs. EVIDENCE: The care plans contain clear information about how people like to be supported with their personal care. In the AQAA the home told us people are given the choice as to who they would like to support them with personal care, and this is respected, if it is not possible for the person of their choice to support them, this is clearly explained. People have the choice of when they want to get up, when they want to bathe or shower, and all personal care is undertaken in private with the utmost respect for privacy and dignity. This means that people get support in the way they prefer. Good records are kept of health appointments and their outcomes. Staff make sure that people are given support to attend appointments to meet their health needs. Everyone has a Health Action Plan that clearly shows what health care Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 16 professionals support them and gives details about specific helath care needs. This means it is easy to find out relevant information quickly. There is one person living at the home who has significant health care needs and is requiring two staff to support them in all areas of their care. The manager is arranging a meeting with a range of helath care professionals to look at this persons long term needs. This will help the person concerned and the home to decide if their needs can continue to be met at Trabel House. The medication system is well managed and people get their medication at the right times. There is clear information about when any ‘as required’ medication should be given. This means that people will only be given these if they are needed. Staff who administer medication have all received training. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and are protected from abuse. EVIDENCE: The home has a clear complaints procedure which is given to everyone when they move into the home. It is also on display by the lounge. In the surveys people told us that that they know who to talk to if they were unhappy about anything. How to make a complaint was also discussed at the last residents meeting. The home has a complaints log in place where staff record any complaint that is made together with the action they have taken to resolve it and the outcome. We saw that two complaints have been made and the manager has dealt with both of them in line with the homes procedure. This means that complaints are dealt with properly. Staff have received training and are aware of their responsibility to safeguard people in their care. The staff we spoke to were clear about what they would do if they felt there were any practices in the home that were not in the best interests of the people living there. This means people are being kept safe. The home does hold money for safekeeping if people want them to. Records are kept of every transaction and receipts are attached for any purchases that are made. This means that people are protected from any financial abuse. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 18 Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is homely, comfortable, well maintained and provides a safe place for people who live at the home. EVIDENCE: Trabel House is in Huddersfield, within walking distance of the town centre and is set in its own well-kept gardens. There are ten single bedrooms in the main house, a lounge, dining room, breakfast room, kitchen and laundry room. The Gate House, which is adjacent to Trabel House, is a two-bedroom bungalow with a lounge/dining room, kitchen, bathroom and store room. The home was fresh and clean when we visited. In the surveys people told us that this is always the case. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 20 There are laundry facilities available that people use, supported by staff. There are infection control policies and guidelines in place. None of the staff have completed formal infection control training. We talked to the manager about this she told us staff will be completing a computerised course to cover this. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 21 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, 33, 34 & 35 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. Staffing levels in the home need to be reviewed to make sure that everyone is getting the care and support they require. EVIDENCE: The main house and Gate House are staffed separately. The staffing levels in the Gate House are appropriate to meet people’s needs. In the main house there are 5 support staff on duty during the day and two support staff on waking night duty. The night staffing levels have been increased so that the moving and handling needs of one person can be met. We asked staff if the staffing levels were adequate. They told us that one person needs two members of staff to support them, as they are currently spending most of their time in bed. This means that there always has to be two staff in the house. People said that this has had effect on the other people living in the house in relation to going out on a spontaneous basis. The manager is aware of this and a meeting has been arranged about staffing. In the interim addition staff should be rostered on duty to make sure other people get the same level of service that they are used to. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 22 On the Annual Quality Assurance Assessment we were told that there are twenty six staff working at the home, sixteen of whom have completed their National Vocational Qualification (NVQ) training in care at level 2/3. All new staff complete an induction course before they start working in the home. Staff also complete the Learning Disability Qualification (LDQ). Staff told us that the training they get is good and relevant to their role. Recruitment files are held at head office. The home has a summary of the checks that have been completed, however, these lacked detail. There were no dates against the Protection of Vulnerable Adult (PoVA) or the Criminal Records Bureau (CRB) checks. In the two files we looked at staff had started their induction before references had been received. We spoke to a member of the team in head office who explained that sometimes people start the induction training course before all the checks are received. These courses are run externally to the home and staff do not have any contact with people using the service. If any of the checks were unsatisfactory a decision would be made about that persons’ suitability before they started working with people. It is important that the records show exactly when checks were received, when staff were completing their induction training and when they started working in the home. This will make it easy to check that the recruitment process is robust and that people working in the home are suitable and safe. The manager has developed a training matrix that clearly shows the training that every staff member has undertaken. This means that she can make sure staff receive updates as and when necessary. She is also aware that staff need to complete Mental Capacity Act and Deprivation of Liberty training so that they fully understand this legislation. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 23 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 and run in the best interests of the people living there. EVIDENCE: The manager was registered with us in January 2009. She has 10 years experience of working with people with learning disabilities. She has completed her NVQ level 4 and the registered managers award. This means that she is qualified to manage the home. The home sent us their annual quality assurance assessment (AQAA) when we asked for it. This a self-assessment tool that focuses on how well outcomes are being met for people using the service. This told us about improvements Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 24 that have been made and what the home hopes to do in the next 12 months. There are some good quality assurance systems in place. The company have their own quality assurance team who visit the home and look at how the home is being managed. These visits highlight any action that needs to be taken to improve the service to the people living there. The area manager should visit the home every month and write a report about how the home is being managed. We could find no evidence that these reports were completed in July and August. It is important that these reports are completed to make sure that home is managed properly. People living in the home are consulted about the way it is managed through residents meetings and through individual consultation every three months. Staff told us that they do their best to act upon people’s wishes. There is a health and safety policy in place. Staff have completed moving and handling, first aid, food hygiene and health and safety training. The manager has recently drawn up a training matrix that shows where people have gaps in their training and when refresher training is due. It was clear from this that staff need to complete fire safety and infection control training to make sure they are working safely. In the AQAA we were told that all of the servicing of equipment and insurance certificates are in place. We looked at the gas safety report and the small electrical appliance test records and found they were up to date. This means that equipment in the home is being kept in good working order. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 25 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 3 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 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 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Version 5.3 Page 26 Trabel House DS0000026308.V377670.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. . 1 Standard YA6 Regulation 16 Requirement Care plans must identify what people’s social care needs are and identify how these are to be met. This will make sure people’s social care needs are met. The staffing levels at the home must be reviewed to make sure there are enough suitably qualified and experienced staff on duty. This will make sure that people’s needs are met. The information about staff recruitment must give details of the dates PoVA and CRB checks were received. This will make sure that staff are suitable and safe to work with vulnerable people. The area manager must write a monthly report about her visits to the home. This will make sure that the manager gets written details about any action that she needs to take to improve the service. Staff must complete fire safety and infection control training. This will make sure that they are working safely. DS0000026308.V377670.R01.S.doc Timescale for action 30/11/09 2 YA33 18 (1) 30/09/09 3 YA34 19 31/10/09 4 YA39 26 31/10/09 5 YA35 18 (1) 30/11/09 Trabel House Version 5.3 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The daily records kept for people should reflect the content of the individual’s care plan and whether or not outcomes of the care plan have been met for the individual. Staff should continue to look at people’s ongoing education and development with them and document their wishes in the care plans. All staff should complete Mental Capacity Act and Deprivation of Liberty training. This will make sure that they fully understand the implications in their day to day work. 2. 3 YA12 YA35 Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 28 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 61 61 61 Email: enquiries.yorkshirehumberside@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. Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 29 Trabel House DS0000026308.V377670.R01.S.doc Version 5.3 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!