Care Home: Underhay House

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What the care home does well Underhay House provides a comfortable and structured life for people living at the home. People are supported to have `lifestyles` which they enjoy, and have chosen. People benefit from their independence being promoted through being offered meaningful opportunities to be involved in the community. There is an `open` atmosphere in the home and people can be confident that they will be listened to. What has improved since the last inspection? The recording of medication administered to people has improved helping to ensure people are kept safe. Improvements have been made to the lounge with a new carpet, new curtains and redecoration helping to provide a homely environment. We have been sent a recent fire risk assessment to show that people are being kept safe. Staff have been updated in mandatory areas of training, including training in safeguarding, to help keep staff informed and to ensure people are being supported consistently and safely. What the care home could do better: Underhay HouseDS0000026624.V377864.R01.S.doc Version 5.3 No requirements have been made. A good practice recommendation is for Health Action Plans to have more detail and for an accessible format to be used to help the people living at the home have a better understanding about the information. Key inspection report CARE HOME ADULTS 18-65 Underhay House 639-641 Muller Road Eastville Bristol BS5 6XS Lead Inspector Sarah Webb Key Unannounced Inspection 15th & 16th July 2009 11.00 Underhay House DS0000026624.V377864.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. Underhay House DS0000026624.V377864.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 Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Underhay House Address 639-641 Muller Road Eastville Bristol BS5 6XS 0117 9519094 01275 372151 underhayhouse@freewaystrust.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Freeways Trust Ltd Mrs Sharon Prowse Care Home 12 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (12) of places Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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 categories: Mental Disorder, excluding learning disability or dementia (Code MD) Learning Disability (Code LD) The maximum number of service users who can be accommodated is 12 16th July 2008 2. Date of last inspection Brief Description of the Service: Underhay House is a care home registered by us to provide personal care for up to twelve people with a learning disability. The home is also registered to admit people with a mental disorder but there are no people living at the home at this time with this as their primary care need. The home is operated by the non-profit making organisation Freeways Trust Ltd. There is a satellite home for three people at 224 Glenfrome Road that is close to Underhay House and which is also registered with us. Both homes are managed by the same person Ms Sharon Prowse. Underhay House is situated in a residential suburb of Bristol on a busy road. The accommodation is of two terraced houses based over three floors. Access to the upper floors is by means of stairs only. Public transport is available close to the house and there are local shops opposite as well as a large supermarket within a quarter of a mile. The home is within quarter of a mile of the M32, an urban motorway that links to Britains motorway system. The home has a pet cat. The home aims to ‘provide a physical and emotional environment that is safe and secure, where responsible risk taking is promoted’ and ‘to respond effectively to the diverse needs of all service users.’ The range of fees is from £502.17 to £680.42. Items such as hairdressing, activities, clothing and personal items are not included in this fee. Underhay House DS0000026624.V377864.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection and was carried out over two days. We case tracked the care and support people using the service receive by looking at various records and documents. These included assessments, care plans, how people are supported in taking risks safely and how they are given their medication. Staff recruitment and training records were also looked at. We were shown around the house and spoke with the Registered Manager, the people living at the home and staff. We looked at information received since the last inspection. This included an Annual Quality Assurance Assessment (AQAA) and monthly reports of the home’s management. What the service does well: What has improved since the last inspection? What they could do better: Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 6 No requirements have been made. A good practice recommendation is for Health Action Plans to have more detail and for an accessible format to be used to help the people living at the home have a better understanding about the information. 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. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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 Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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, 3 & 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. People who want to use the service are given information to help choose a home that will meet their needs. People moving to the home can be assured their needs will be met through an assessment and review process. People wanting to move to the home have the opportunity to visit to help them make a choice. EVIDENCE: Since the last inspection the Manager had updated the Statement of Purpose to reflect staff changes. A Service User Guide provided information for new people wishing to use the service. This was in an easy read format that helped people to understand what the home had to offer. Since the last inspection there have been three new people admitted to the home. All three people had chosen to move to Underhay House from another Freeways care home that was in the process of deregistering. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 9 Care files showed that one person had an assessment of their needs carried out by a social worker before moving to the home. Although there were no current assessments carried out for the other two people, social workers had been involved in their move, and had reviewed their care agreeing their needs would be met by the home. One person had been supported by an advocate to help them make choices about where they wanted to live. This support is still continuing. The Manager told us the people had the opportunity to visit the home on several occasions before moving in. This was confirmed by an individual spoken with. They told us “I visited with staff”, and “I like Underhay and have friends here”. The existing people living at the home knew the three new people through various Freeways activities. They had been consulted with and were happy for the people to move to the home. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are involved in the planning of their care and how they want to be supported with their needs. People are involved in making decisions about their lives and in all aspects of living at the home. Risk assessments support people to take risks as part of their lifestyle. EVIDENCE: The home had continued to encourage people to make choices about how they wanted to be involved in the planning of their care. It was evident from looking at one person’s Person Centred Plan that actions had been recorded and agreed. They had wanted to go on a trip to Africa and this had been planned with them. The Manager told us the trip was going ahead in the next few weeks. Person Centred Plans were in easy read formats with pictures so Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 11 that people had a better understanding of the information about their wishes and their care. We saw three peoples’ care files. Information included Social Services care plans, Freeways assessments, monthly key worker packs, health action plans, and reviews of their care. Peoples’ needs had been reviewed regularly and included comprehensive and clear information about all aspects of their care and lifestyles. Some peoples’ information in their care files related to their previous home and was now not relevant to their new placement. The Manager ensured us these areas of paperwork would be sorted appropriately. A key working system was in place where each person had a named member of staff who played a key role in helping them to plan the services they want. Records were seen of monthly key worker meetings with information that had supported reviews and helped monitor peoples’ care. The AQQA told us staff are being trained to complete information more thoroughly as this is an area that has not always been consistently followed. A ‘day file’ recorded peoples’ activities every day. This also helped to provide information for the monthly reviews. People had been encouraged to make choices and decisions about the routines of the home and their individual lifestyles. This was seen in written minutes from meetings. We also spoke to two people who told us about some of their preferences and that staff supported them with their choices. People had also been helped to voice their opinions through Freeways forums and working groups involving them in writing policies. The Manager has recently been trained in British Sign Language (BSL) so that she can communicate with people who have a hearing loss. She had organised for an individual with hearing loss to also help the staff team to have a better understanding of signing and improve their communication skills. Further to this it is being planned that all fulltime staff attend training to BSL Level 1. This is good practice. People had a number of risk assessments that were seen. The home had supported people to take risks as part of their lifestyle and these had been reviewed regularly. Risk assessments were also discussed at peoples’ reviews. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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, 14, 15, 16, & 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to access leisure and educational facilities locally and in the wider community. Each person’s rights and responsibilities are recognised in their daily lives. A healthy and balanced diet for each individual is promoted. EVIDENCE: People using the service were seen going out to various activities, day services, and college placements. A few people were in paid employment. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 13 Two people spoken were able to confirm they went to church regularly, attended college and an advocacy group, went out for meals and to the pub, and attended various clubs. Individual daily records also showed how people had been supported by staff to use community-based facilities. These included shopping, cinema, swimming and evening activities held at another home in the organisation such as darts. The Manager explained Freeways had reviewed its day services and that it would be closing this service to people in the future. Due to this an Employment Coordinator had been recruited who had begun to talk with people about what they would like to do during the day and the sort of work they would like to be involved with. Holidays had been arranged on individual preferences and were supported by the staff team. An individual told us they had been on holiday to Spain. As previously recorded some people will be going to Africa soon. People had been supported to maintain close contact with their families and friends. Some people regularly visited their families and visitors were welcomed to the home. This was seen through daily notes of peoples’ activities. One individual told me they regularly met their friend for lunch. Individual care files showed how people had been supported in being actively involved in the running of the home. A household task rota was seen and this was discussed at meetings. A ‘life skills’ day at home helped people to go to planned appointments, activities and keep their bedrooms clean. Menus seen showed that a choice of food is offered that is varied, wellbalanced with healthy eating options encouraged. Alternative food is provided if people do not want the main meal. This was confirmed by two people spoken with who told us “Staff cook me something else if I don’t like the meal”. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported in their preferred manner and their personal and healthcare support needs are met. People would benefit from Health Action Plans being in an accessible format. The home has responded robustly to medication errors and has ensured staff had received training so that each individual’s welfare and safety was promoted. EVIDENCE: Peoples’ healthcare records provided guidance for staff on how they should support those living at the home with their personal and health care. However more detail is needed in peoples’ Health Care Plans with a more accessible approach. People would benefit from their plans including pictures and photographs. Healthcare records showed that people had been registered with a local General Practitioner (GP), dentist and optician. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 15 There had been varying levels of support from other health care professionals such as the Consultant Psychologist, Occupational Therapist, and Physiotherapist. Contact with these professionals had been recorded in individuals’ files and the outcomes acted upon. The home has a medication policy and procedure. The location of the medication has been moved to another area in the dining room that is better suited for administering medication. Medication records seen contained a medication profile of each person. Photograph of each person were seen, consent sheet, manufacturer’s notes of all prescribed medication, details of any medication taken as and when needed (known as ‘As Required’), signatures of each staff member who administered medication together with a sample of the initials they used on some of the records. Records of the medication entering the home and being returned to the pharmacy had been maintained. Some of the stock control records were seen and these corresponded with the balances of those medicines seen. Since the last inspection, although we had been told about three occasions when there had been medication errors, the home had generally improved in this area. However, we had also been told about the most serious error when someone was not given their medication at a set time. The Manager had responded robustly to this bad practice. It was evident she had made it clear to all staff the seriousness of the error and staff have since been further trained with their competency observed by senior staff. The manager said staff would not be able to administer medication unless deemed competent in carrying out this task. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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. The people that live at the home feel comfortable with raising concerns with staff and that these are acted upon and recorded. People can expect to be protected from abuse by staff trained in abuse awareness. EVIDENCE: The home has a comprehensive complaints policy. People spoken to said they knew how to make a complaint and told us who they would speak to. We looked at the home’s complaints log, which had seven complaints recorded since the last inspection. It was evident that the people living at the home felt confident in making a complaint. All had been dealt with appropriately with a record of the outcome and action taken. We have not received any complaints or concerns direct regarding Underhay House. The organisation has a policy and procedure for the protection and safeguarding of people. The home had followed local safeguarding protocol and had reported allegations and suspicions of abuse so that they were investigated Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 17 appropriately. Staff had received training in understanding abuse and safeguarding through their initial induction and with annual refresher training. Training records showed that ten staff had attended an annual safeguarding update on 10/12/2008. This meets the recommendation for staff to be updated in this area. The manager told us she was meeting with the safeguarding trainer to book other staff to be trained. The Manager and Assistant Manager had also received safeguarding training for Managers. All staff had an enhanced Criminal Records Bureau (CRB) check and checked against the Protection Of Vulnerable Adults (POVA) first list before starting work at the home. The majority of staff had received training in working with people who may present challenges. However the AQAA highlighted that the home is aware that this is an area that needs to be improved. Care files showed reactive strategies in place indicating triggers and indicators that helped staff know when people needed support if unhappy. This helped to ensure there was consistency in supporting individuals with their different behaviours. A ‘behaviour log’ recorded significant episodes and action taken. The organisation operated a safe financial system for supporting people with their finances. Financial risk assessments were seen to help protect people from financial abuse. These included an assessment of peoples’ understanding of money and financial management. The home employs a member of staff who is responsible for only book keeping and had kept the finances up to date weekly. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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 & 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. Improvements made to the home provide people with a comfortable, clean and more homely environment. EVIDENCE: Underhay House is a two terraced house based over three floors and in keeping with the local neighbourhood. The house is on a busy main road in a residential area. There are good public transport links to Bristol city centre and surrounding areas. Amenities are close by including a large supermarket and shopping complex. We were shown around the house and saw there had been several improvements made to the environment for the benefit of the people living there. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 19 These included a new ground floor walk in shower that had been completed providing an accessible bathing facility. New flooring had also been laid in a communal area next to the dining room, and the lounge had been re carpeted and decorated. There are still a few areas that need maintaining but the manager has put in requests for these including bathroom tiles to be re grouted. A new back gate has been ordered as the existing one has been repaired on several occasions. The home was generally clean with a part time cleaner employed to clean the main shared areas of the home. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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): 31, 32, 34, 35, & 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home benefit from a staff team who have a good understanding of their role and responsibilities and who are trained and supervised to meet the individual needs of people. People benefit from recruitment policies and procedures that help to keep them safe. EVIDENCE: A member of staff spoken with demonstrated their understanding of the aims of the home, their role and responsibilities, and a good knowledge of peoples’ needs. The staff team consisted of thirteen staff, including both part and full time support workers, and one part time cleaner. Three staff had been on duty during evenings and with two staff during the day. Staffing also included one of the staff supporting two people living at Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 21 Glenfrome, a sister home nearby during the evening. Two staff had covered sleep in duties. Three staff recruitment records seen confirmed that the Manager follows the homes recruitment policies and procedures. This was seen through staffing files that had appropriate information such as a completed application form, evidence that a Criminal Records Bureau check had been carried out, and two satisfactory references. A record of new staffs’ induction period had been recorded showing they had been supported in their role. Six staff had completed a National Vocational Qualification (NVQ) while five staff are in the process of completing. We saw a recent summary of the Manager’s Staff Training and Development activity and outcomes. This included a rolling programme of mandatory training. Training records showed they had either attended training in first aid, manual handling, and food hygiene or had been booked to attend. Specialist training staff had attended included diabetes awareness that had been provided by an external healthcare service. The Manager is a trainer in Autism and is developing a training session for the staff team. Records of supervision showed staff had received regular formal supervision. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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. People living at the home benefit from a well run home with good outcomes for people with systems in place that promotes and protects their health and safety. The views of the people who live in the home are sought and acted upon. EVIDENCE: Ms Sharon Prowse is competent and experienced to run the home. She has a National Vocational Qualification (NVQ) level 3 and is in the process of completing NVQ in Leadership and Management. She has updated her training in appropriate areas for the benefit of the people living at the home. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 23 People had been encouraged to speak up and their views had been asked for through regular house meetings and annual reviews. These were seen through written records of meetings and questionnaires completed by five people during June 2009. The out come of these was positive. We also saw positive feedback from five families who had responded to questionnaires. A recommendation has been met for the home to send us a current fire risk assessment. Since the last inspection the fire services has visited the home and action has been taken in response to recommendations made. Records seen confirmed staff had completed annual fire training in the awareness and prevention of fire. Records confirmed a weekly health and safety check is completed and requests for any maintenance are sent to the head office. The home has notified us of any information regarding changes affecting peoples’ welfare. The home has received monthly visits from other Managers’ who monitor the all aspects of the management of people’s care and health and safety. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 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 3 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 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 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 3 x Version 5.3 Page 25 Underhay House DS0000026624.V377864.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations Provide more detail in peoples’ Health Action Plans in an accessible format. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission 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. Underhay House DS0000026624.V377864.R01.S.doc Version 5.3 Page 27 - 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. 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