Care Home: Wallace Mews

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What the care home does well Staff are respectful and sensitive with people when helping them or when speaking to them. Visitors are always welcomed and there are links with the local community. A programme of activities is available so that people can enjoy social and leisure events. Information about the home, advocacy and events are readily available in the reception entrance. The recruitment procedures are properly followed which help prevent risk to those living in the home by making sure that the right checks are carried out before staff start work. The environment has been purposely designed to meet the needs of the people using it. The home is decorated in a modern style and has a range of specialist equipment. Service users have brought some small items with them making their own bedrooms individualised and homely. The meals are nicely cooked with choices available. Information is available should anyone have a concern or complaint about the care or service they are receiving. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. Comments from surveys returned to the Commission included: "I am happy living here". "I would speak to the manager or social worker if I was unhappy." "I would like to stay here." Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 One relative commented: "The home does most things well" Staff said: "We support people in activities and give support and care and promote a good quality of life." What has improved since the last inspection? The preadmission process is now comprehensive and completed by the person, relatives, care managers, other professionals and the registered manager. People have a six week assessment and stay in the home over a period of time so that they can get to know the routines and everyone. This makes sure that the person chooses the right place to live. Staff have worked hard to make sure the care plans are clear and detailed about the care provided. Service users and their representatives are now involved in planning their own care with staff. Information about people`s past lifestyles and choices are now written down so that staff can continue to support them or help them get help from others. Risk assessments are detailed and show how people are being supported and protected. Medication policies and procedures are now followed. Staff now receive on going training so that they can care for the different needs of people living in the home. They have completed safeguarding training and feel confident that they can recognise signs of abuse would be able to raise an `alert` and protect those at risk. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. An appropriate washing machine has been provided and infection control risks minimised. The staff keep in contact with specialists so that people are given sufficient guidance to enable them develop and maintain personal relationships. This ensures people make appropriate decisions and friendships, which keep them safe. The registered manager makes sure that staff have formal supervision and gives direction on a daily basis so that people receive person centred care. The Company`s quality assurance systems are in place so that people receive consistent quality of care and their views are taken into account. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 The manager is now registered with the Commission. What the care home could do better: The care plans should continue to be improved and provide detailed moving and handling procedures, so that people receive consistent, safe care. The staff need to continue to develop a person centred approach to care delivery so that people can continue to lead purposeful, independent lifestyles. Two signatures are needed when handwriting directions on the medicine records so that errors are avoided. All staff need to complete dealing with challenging behaviour training and make sure behaviour monitoring charts are completed. This will make sure people are protected and staff deliver consistent care. The practice of wearing "clinical" uniforms should be reviewed. The risk assessments for the balconies should be reviewed with the Health and Safety Executive. Key inspection report CARE HOME ADULTS 18-65 Wallace Mews 230 Mowbray Road South Shields Tyne and Wear NE33 3BE Lead Inspector Irene Bowater Key Unannounced Inspection 10th June 2009 10:00 Wallace Mews DS0000067985.V376016.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. Wallace Mews DS0000067985.V376016.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 Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wallace Mews Address 230 Mowbray Road South Shields Tyne and Wear NE33 3BE 0191 4541551 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) karen.wallacemews@hotmail.co.uk Minster Pathways Limited Karli Wynne Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12), Physical disability (12), of places Physical disability over 65 years of age (12) Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2008 Brief Description of the Service: Wallace Mews is a purpose built home providing personal and social care for up to twelve people with physical and or learning disabilities. The home no longer employs registered nurses and therefore cannot provide dedicated nursing care. Should anyone need any nursing intervention this is supplied by the community nursing services. The home has two storeys with level access on both and lift access between the floors. It has been equipped to a good standard with many adaptations especially suited to the client group it intends to serve. It is located in a quiet suburban area close to the sea front, and the Lees Nature Reserve at South Shields. It is close to many of the town’s amenities such as the marine park, theatres, restaurants and entertainments, as well as the shopping centre. The Statement of Purpose And Service User Guide set out what the home can offer and copy is provide to each person on admission. Fee rates range from £1,123.04 to £1,370.00. Wallace Mews DS0000067985.V376016.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 two star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: Information we have received since the last visits on the 8 December 2008. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The provider’s view of how well they care for people. The views of people who use the service and their relatives, staff and other professionals. 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 services 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. The Visit: An unannounced visit was made on the 10 June 2009. The visit was carried out by one Inspector and took six hours to complete. During the visit we: Talked with people who use the service, relatives, staff, the manager and visitors. Looked at information about the people who use the service and how well their needs are met. Looked at samples of other records that must be kept. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 6 Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last visit We told the manager what we found. What the service does well: Staff are respectful and sensitive with people when helping them or when speaking to them. Visitors are always welcomed and there are links with the local community. A programme of activities is available so that people can enjoy social and leisure events. Information about the home, advocacy and events are readily available in the reception entrance. The recruitment procedures are properly followed which help prevent risk to those living in the home by making sure that the right checks are carried out before staff start work. The environment has been purposely designed to meet the needs of the people using it. The home is decorated in a modern style and has a range of specialist equipment. Service users have brought some small items with them making their own bedrooms individualised and homely. The meals are nicely cooked with choices available. Information is available should anyone have a concern or complaint about the care or service they are receiving. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. Comments from surveys returned to the Commission included: “I am happy living here”. “I would speak to the manager or social worker if I was unhappy.” “I would like to stay here.” Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 7 One relative commented: “The home does most things well” Staff said: “We support people in activities and give support and care and promote a good quality of life.” What has improved since the last inspection? The preadmission process is now comprehensive and completed by the person, relatives, care managers, other professionals and the registered manager. People have a six week assessment and stay in the home over a period of time so that they can get to know the routines and everyone. This makes sure that the person chooses the right place to live. Staff have worked hard to make sure the care plans are clear and detailed about the care provided. Service users and their representatives are now involved in planning their own care with staff. Information about people’s past lifestyles and choices are now written down so that staff can continue to support them or help them get help from others. Risk assessments are detailed and show how people are being supported and protected. Medication policies and procedures are now followed. Staff now receive on going training so that they can care for the different needs of people living in the home. They have completed safeguarding training and feel confident that they can recognise signs of abuse would be able to raise an ‘alert’ and protect those at risk. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. An appropriate washing machine has been provided and infection control risks minimised. The staff keep in contact with specialists so that people are given sufficient guidance to enable them develop and maintain personal relationships. This ensures people make appropriate decisions and friendships, which keep them safe. The registered manager makes sure that staff have formal supervision and gives direction on a daily basis so that people receive person centred care. The Company’s quality assurance systems are in place so that people receive consistent quality of care and their views are taken into account. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 8 The manager is now registered with the Commission. 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. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4. 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 receive clear information about the service and good assessments of need before admission. This helps them make informed decisions about whether to use the service. EVIDENCE: The Statement of Purpose and Service User Guide has been reviewed and updated as a bungalow has been built in the grounds and this is to provide care for people with complex needs. The bungalow has been completed but is not yet registered with the Commission. Each person is provided with a Service User Guide which is in written and picture style. Staff also guide the person through the information so that they can understand what the service provides. This information includes how peoples preferences and choices will be supported, including personal beliefs, religious preferences, equal opportunities and disability discrimination. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 11 Since the last visit to the home the new manager has introduced detailed preadmission and admission assessments. Care managers assessments are also provided and the assessment process takes about six weeks, with people staying for a couple of days at a time so they can become used to the routines, staff and other people living in the home. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. 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. Choices and risk taking are now being managed and planned in a person centred and safe way. This means people are able to take risks regarding their lives, have appropriate levels of independence and are protected as far as possible. EVIDENCE: Each person has a care plan which includes detailed risk assessments and a range of information about a person’s previous lifestyle and current goals and aspirations. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 13 Risk assessments include pressure ulcer risk, moving and handling, nutritional assessments, continence and risk management plans for behaviours that may challenge. The management of risks now addresses how people are to be protected and supported, for example when going out alone, vulnerability when forming relationships within and outside of the home and managing their own money. Some people have behaviours that may challenge and information is available to show what the behaviours are, what the triggers might be, and any management strategies, monitoring or recording arrangements. However one person can become disruptive at night and the care plan does not specify the action to be taken by all staff so the person receives consistent interventions. There is also a risk that a person may run away from the service. There are now photographs and a detailed missing person’s procedure which has been followed to protect the person from any harm. Each person is given a key worker who then supports the person to prepare a care plan. Since the last visit the style has changed and they are now clear, easy to follow and also have pictures for those who may find the written word hard to understand. The key worker reviews the care plan each month with the person. This makes sure that any issues can be discussed and changes made to the plan of care. People are now able to have say about how the home is run. Meetings are now held on a regular basis, there are opportunities to help with the newsletter and one person wants to help edit it each month. They are also asked to complete questionnaires every three months, the results are then published and changes made to routines if necessary. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16,17. 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. Opportunities to take part in meaningful activities and keep control of everyday decisions are good and mealtimes are organised. This means people live full and active lives. EVIDENCE: The manager has worked hard since the last visit so that people are able to develop their chosen lifestyle. Care plans now show how activities are planned based on individual choices. On the morning of the visit the home was busy with people attending college, going shopping, sitting in the sun, doing nothing and two people had hospital appointments and were supported by care staff. In the afternoon some were Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 15 going to an art studio and others enjoyed making and tasting smoothies (milk shakes) prepared with fresh fruit. There is evidence that staff support people to maintain and develop links with the local community through visiting the library, the local pub and going out for meals. Other activities include a computer course, photography course, cookery lessons in house, attending a local art studio, swimming and the manager is hoping that some may be able to join a horse riding club. Some have a bus pass which lets them to travel throughout Tyne and Wear, with support if needed by a support worker. Staff are wearing “clinical” uniforms which do not support the ethos of the home and does draw attention to everyone when out and about. There are photographs of events and plenty of equipment available in the home, including large screen televisions, audio equipment, DVD’s and Wii player. Swimming is now in the weekly activities and a request has been made to a specialist horse riding club in the area for a number of people. There are also plans to develop a vegetable garden and people have responsibility to care for the pet rabbit. The manager has worked with individuals and care managers to support younger people develop an understanding of personal and sexual relationships with others. This should help protect the more vulnerable people living in the home. Meals are planned around people choices and are changed accordingly. Most have cereals and toast for breakfast with a light lunch and main meal in the evening, although snacks drinks and fruit are available at any time. Lunch choices were quorn chicken nuggets, sausage casserole and assorted sandwiches. Hot and cold drinks and fresh fruit were available. Staff gave support discreetly, where needed, and the mealtime was a pleasant, sociable occasion. The evening meal choices were Mediterranean chicken, creamed spaghetti with mushrooms, cheese burgers, apple spice cake and custard and banana split. The cook said some would not want any of this and she would then cook what Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 16 they preferred but she always liked individuals to try different foods. A menu book shows a vast range of choices and variations for all meals. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care is now being planned and delivered in a respectful and person centred way. This enables people to fully access healthcare and other services and ensures their needs are supported. EVIDENCE: The manager has introduced a “person centred” approach to care planning and care delivery and staff have worked hard to improve the care plans since the last visit to the home. There is evidence that staff are working with the person, their relatives and care managers to find out about their previous lifestyles and histories. This information is then used in promoting people’s independence and choices about daily living. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 18 Advice is also sought from speech and language therapists, dieticians, occupation therapists, psychiatrists and continence advisors. Care plans are written with the individual and give details about personal characteristics, previous life history, preferences for male or female carer, religious beliefs and current health status. Information is available in written and picture style regarding nutrition, continence, falls, personal care, activities and relationships. Risk assessments are now in place for those people who may have seizures. And care plans are specific about how these episodes are managed by staff. Plans detail appointments for hearing, dentist, GP, well woman, well man appointments, chiropodist and outcomes are recorded. There is District Nurse input for one person who has a catheter and pressure damage. And there is plenty of specialist equipment available such as profiling beds, air flow mattresses and cushions. Information about how people are transferred is available but do not detail which hoist, sling and how staff are to carry out the task. People who do have poor appetites and weight loss have their weight regularly checked and staff contact the dietician and Speech and Language Therapists should there be any concern. The home has clear medication policies and procedures for staff to follow. Medication is now only administered by senior staff that have been trained. Medicine storage has improved with the room kept tidy and medicines all locked securely. A Controlled Drug check was correct and there were no gaps on the Medicine Administration Records (MAR). A number of handwritten entries on MAR charts had not been countersigned by a second person to confirm their accuracy. The drug fridge was locked and the temperature is checked daily. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good complaints and protection procedures are now in place and effectively followed to ensure that people are listened to and protected from abuse. EVIDENCE: The Company have clear, accessible complaints policies and procedures. These are available in a picture style and are in each person’s care plan. At the entrance to the home is a comments book where people can record any complaints or compliments they have about the service. People can voice concerns at meetings, at monthly reviews or by talking to the manager in private. Questionnaires sent out quarterly and any concerns are responded to within twenty eight days. One complaint has been received at home level since the last visit has been resolved. There have been no safeguarding referrals since the last visit and the safeguarding referral made in December 2008 has been fully investigated and resolved, with management plans in place to minimise risks for those involved. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 20 Staff now have had safeguarding training and would benefit from further challenging behaviour training. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29,30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is a comfortable, pleasant place to live and it is well maintained to encourage people’s independence. EVIDENCE: The home is purpose built over two levels. There is an accessible car park to the rear of the home and all areas are accessible to wheelchair users. A bungalow has been built in the grounds of the home. The Provider hopes to register the service for people with complex needs. There are lounges and dining rooms on both floors although the upper floor facilities appear to be more popular. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 22 All of the communal areas are pleasantly furnished and decorated and reflect the age group of the people living there. There is some damage to walls and doors from wheelchairs and trolleys. Also there is some damage to the laminate on front of a cupboard due to heat from the toaster. All of the bedrooms are large and have full en suite facilities. There are good adaptations including overhead hoists, profiling beds and wet room showers are available. One person with very limited mobility has the use equipment that enables more independence to turn over, use the television, lights and press the nurse call. People have also been encouraged to personalise their own space and there are lots of posters, DVD’S, personal computers, and religious items displayed in their own rooms. Previously all bedroom doors had “swipe card” keys. Ordinary keys are now provided although the front door has automatic access. Bedrooms upstairs have their own balcony and risk assessments are available although advice from the Health and Safety Executive should be sought to ensure the risks are minimised. The laundry is on the lower floor and is domestic in style. There is no hand wash facility in the room and none of the machines has a sluice wash service. New washing machines are due to be installed week beginning 15 June 2009. The home is clean with no odours and reflects the age group of the people living there. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,34,35,36. 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. Systems around selection, recruitment and training of staff are good and makes sure people are protected from harm. EVIDENCE: Currently there are twelve people living in the home. During the day there is a manager who is supernumerary and five care staff, one being a senior carer. In addition there is a domestic, a cook and a maintenance person who is shared with a sister home. Overnight there are two waking staff, with the manager on call. There are plans to employ a deputy manager once the bungalow has been registered and is occupied. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 24 The majority of staff have completed National Vocational Training (NVQ) level 2 and some have NVQ level 3 and one senior is completing level 4. New staff have an induction period, which is over twelve weeks and follows the “Common Induction Standards” from Skills for Care. All staff have completed mandatory training and specialist training includes continence care, epilepsy, challenging behaviours and bipolar management, safeguarding and alerter training, and Learning Disability Framework Award. Some staff are also completing equality and diversity, dementia, nutrition, health and safety and safe handling of medicines. Over the last year there has been many changes and the staff are now starting to work together and understand their roles and responsibilities through formal supervision and with the manager directing everyday practice. Also there are regular staff meetings where care practices and development of the service are discussed. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, two written references and proof of identity. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run by a manager who makes sure that good quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: The Manager is now registered with the Commission and has started National Vocational Qualification level 4 and the Registered Managers Award. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 26 She has a good understanding of where the home needed to develop and has worked hard to introduce person centred care, supervision of staff and give autonomy to those living in the home via meetings, forums, contact with care managers and relatives. Quality assurance systems are now in place including end of stay questionnaires, three monthly questionnaires and daily discussion with those living in the home. Comments from end of stay questionnaires included: “The home is very clean and tidy”. “Staff helpful.” “Made me feel at home.” “Food very nice.” “Care first rate, entertainment brilliant.” “Really enjoyed my stay.” People are being supported to manage their money whenever possible and they have access to their records whenever they wish. Staff confirmed that their views are listened to and they also have regular meetings and they said they can approach management at any time. The AQQA was completed and returned when asked for and the information showed what improvements are planned for the next year. Accidents are recorded and the manager has started monthly analysis to track trends so that the same incidents and accidents can be prevented as far as possible. Internal maintenance records and external contracts are available and up to date. Staff have completed training in safe working practices. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 3 36 3 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Version 5.2 Page 28 Wallace Mews DS0000067985.V376016.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA18 Regulation 13 Requirement The registered persons must ensure that detailed information is provided about use of hoists and slings when transferring people. This will make sure that staff keep people safe when moving and handling. The registered person must ensure that all staff complete dealing with challenging behaviour training. This will make sure people are protected and staff deliver consistent care. Timescale for action 31/08/09 2 YA23 13 01/10/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that the care plans continue to be developed and individuals are encouraged to live independent lives. DS0000067985.V376016.R01.S.doc Version 5.2 Page 29 Wallace Mews 2 3 4 5 YA9 YA13 YA20 YA42 It is recommended that behaviour monitoring charts are always used so the people receive consistent care. It is recommended that the clinical staff uniforms are not worm when out with people who live in the home. And a more casual style of uniform if any is promoted. It is recommended that two witness signatures are available when transcribing handwritten directions on the MAR charts It is recommended that the risk assessments for the balconies are discussed with the Health and Safety Executive. Wallace Mews DS0000067985.V376016.R01.S.doc Version 5.2 Page 30 Care Quality Commission North Eastern Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@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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