Inspection on 14/04/09 for 330 Westward Road

This is the latest available inspection report for this service, carried out on 14th April 2009.

CQC found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

330 Westward Road 29/11/05

330 Westward Road 11/05/05

330 Westward Road 15/02/05

330 Westward Road 26/05/04

330 Westward Road 09/12/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 330 Westward Road 330 Westward Road Ebley Stroud Glos GL5 4TU     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Paul Chapman     Date: 0 6 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: 330 Westward Road 330 Westward Road Ebley Stroud Glos GL5 4TU 01453823852 01453823852 jenny.miles@hft.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Home Farm Trust Ltd care home 8 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: Date of last inspection Brief description of the care home 8 330 Westward Road is a three storey detached house with accommodation for eight adults with learning disabilities. The home is conveniently situated in Stroud, which enables service users to access local community facilities. Service users also have access to transport that is provided by the home and this enables them to access facilities in several other local towns. The home is staffed 24 hours a day, seven days a week. Family and friends are welcome to visit the home at any time and service users can meet them in private if they wish to. The service users attend various activities, which include Day services provided by Home Farm Trust at their Frocester Manor site and College courses. Some of the service users are also employed locally. Care Homes for Adults (18-65 years) Page 4 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection site visit was completed over 2 days, Tuesday 14th April and Wednesday 6th May 2009. The registered manager was not present at the visit, but was present throughout the 2nd visit. Before completing the site visit we received the completed AQAA (Annual Quality Assurance Assessment) from the manager. The AQAA asks a service provider to identify how they believe the service performs against the National Minimum Standards and how they evidence this. It also asks them to identify how the service has improved since the previous inspection, and their planned improvements for the coming 12 months. We review this information along with any other information we have collated about the service since the previous inspection was completed. This information may come from questionnaires received from people using the service, their relatives, other Care Homes for Adults (18-65 years) Page 5 of 30 professionals involved with the service, notifications from the service and any concerns and complaints we may have received. This enables us to develop a hypothesis for the inspection site visit. At the 1st site visit an expert by experience supported us speaking to 2 people living in the service about what they thought of it. Whilst we were at the service we spoke to people living there, staff and observed interactions between people. In addition to this we examined a range of documents relating to peoples care needs being assessed and met, whilst ensuring their safety. What the care home does well: What has improved since the last inspection? The standard of the accommodation has always been of a high standard and this continues to be the case with an ongoing programme of maintenance led by peoples needs and choices. A thorough quality assurance assessment has been completed which highlights shortfalls and identifies corrective actions to be taken by the manager and her team. Care Homes for Adults (18-65 years) Page 7 of 30 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 set out 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. Care Homes for Adults (18-65 years) Page 8 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The only admission to the home since the previous inspection was completed has been successful but there have been significant failures in the process which in other circumstances may have caused unnecessary risks. Evidence: One person has been admitted to the service since the previous inspection was completed. At the time of our visits we found it difficult to find all of the information to support the assessment/admission process. After completing the site visit the service manager wrote to us and explained all of the actions taken as part of the admission. After speaking to them it was clear that a substantial amount of work had been completed before the person was admitted. The shortfall comes with the recording of this process and storage of the documents to support the process. It was agreed with the service manager that in future admission processes there would be better records management to enable the reader to have a clear understanding of the Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: admission/assessment process. We asked the person for their opinion of their admission to the home. They confirmed that they had received a Service Users Guide and a Statement of Purpose, and that their visit to the service had been really helpful. They stated that Its really nice here. Each person living in the home should have a contract that details what they should expect from the home. We were unable to find a contract for the person admitted to the service since the previous inspection. It becomes a recommendation of this inspection report that this is addressed. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed and support plans are created that identify those needs and the actions required by staff to address those needs consistently. People are empowered to make decisions about their lives and the service is led by their needs and wishes. Risk assessments are in place that identify and minimise potential risks to enable people to take acceptable risks. Evidence: In the week before we completed the first site visit the home had gone live with HFTs SPARS (Support Planning Assessment Recording System). This is a computer based system to record peoples care and support needs. As part of the process of moving peoples records to this system the manager and staff have re-assessed peoples needs. Assessments we examined covered the following areas: - support needed with personal care, to keep healthy, with looking after their home and tenancy, with employment, college and day services, leisure and hobbies, Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: maintaining friendships and relationships, cultural aspects of life, managing money and dealing with paperwork, challenging behaviour, with issues around consent. All of the assessments we examined provided a good level of detail about peoples needs. From these assessments staff complete support plans to address the identified needs. We examined a sample of support plans developed from these assessments. This showed that detailed guidelines were in place explaining the persons needs, and what actions staff should take to support the person consistently. Each person has a Person Centred Plan (PCP) and a member of the team is a PCP facilitator. It is their role to develop a PCP with each person. To achieve this they meet with people every 6 weeks to discuss their PCP and goals. We saw evidence of these meetings being completed, and speaking to people they confirmed that their goals were being met. PCPs are not yet on the SPARS. The support plans and PCPs we sampled provided good evidence of people being given choices and empowered to make decisions about their lives. When speaking to people individually we asked them about making choices and decisions. People gave examples of activities they complete, hobbies they maintain and goals they have identified. Comments included, I am able to choose what I like to do, and staff give me support when I need it. Each month staff complete a detailed monthly report for each person. The sample we examined provided the reader with a good level of information about what has happened in that month. The information recorded includes activities people have completed, medical inputs and any other relevant information. These will now stop as SPARS creates a similar list. With the support plans only recently going live they were not due for review at the time of this site visit. HFT has a computerised risk assessment tool and each person has a range of risk assessments in place to minimise day to day risks. All risk assessments are printed off and copies are available for people to sign confirming that staff have explained the assessment to them. All of the risk assessments we sampled had been reviewed regularly. We received 7 completed questionnaires from people in the home which made positive comments about the care they received. Care Homes for Adults (18-65 years) Page 13 of 30 Care Homes for Adults (18-65 years) Page 14 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this 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 lead active lifestyles and are empowered to make decisions about what they would like to do. The service provided is led by peoples needs. Evidence: People living in the home lead active and varied lifestyles. We spoke to 4 people individually who all agreed that they were happy living in the home and enjoyed their social lives, examples of this included: To the rear of the property there is an outbuilding that has been converted into an art room. Staff regularly support people to complete art projects. One person has recently completed a course is stone carving. This came about after they expressed an interest to staff. As a result of their course they created a sun dial. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: People go walking with a local rambling group (once a month), people go shopping locally, 1 person works at the wildfowl trust weekly and another person is being supported to find a job locally. Other activities that take place regularly include aromatherapy, using a local gym, pottery, cookery and literacy at local college, 1 person is part of a local History group, and another person is part of a local dance group, people visit the local library, attend the Phab social club, day services at Frocester manor, swimming and amateur dramatics. Holidays were being arranged at the time of this site visit. People living in the home have started up a social group which meets in the afternoon and plays games like bingo and beetle drive which people enjoy rather than watching TV. 2 people enjoyed cooking at the local college but they are no longer able to attend due to health issues. So, the home now has a small cookery group on a Thursday morning to enable them to continue developing their skills. There is a housework rota where people are asked to do tasks including washing, cleaning their bedroom/flat/bathroom, kitchen, lounge and hall and landing, laundry, cooking meals, washing up and loading the dishwasher. There are weekly house meetings and minutes are put on the notice board in easy read format. From looking at these minutes they showed that everyone was given the opportunity to give their opinion and make choices. Friends and family are welcome at the home, and people can see them in communal/or private areas if they wish. People take it in turns to help prepare the evening meal and we saw a rota for this. Speaking to people about this task they commented that they enjoyed it. 1 person said we get what we want to eat. Menus clearly stated that lunch was own choice. Whilst we were in the home we witnessed people getting their own lunches, staff provided support as required. We asked 1 person what their favourite meal was, looking at the menu it was going to be served the next day. All people are involved in planning the menus, shopping and the preparation of food. To minimise potential risks to people while preparing food all of the people living in the home have completed a food hygiene course. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: In addition to speaking with people comments and answers in the completed questionnaires we received supported the other evidence we gathered. Information from the expert by experience interviewing 2 people in the home included, They both said they liked living here. They are both quite independent and go out by themselves but staff support them to go out and do things in the community if they want them to, 1 person said they like the food and can make a drink when they want one, They all choose the room colours when their home is decorated, Friends can stay the night if they want, including partners, They both use public transport and the house car. Care Homes for Adults (18-65 years) Page 17 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 personal care needs are identified in support plans that provide staff with detailed guidelines to meet people needs consistently. Peoples health needs are addressed by appropriately qualified and experienced professionals as required. Medication administration is managed effectively and this minimises potential risks to people. Evidence: As identified earlier in this report each person has detailed support plans created from recently completed assessments. We examined a sample of support plans created for meeting peoples personal care needs, these clearly identified the persons needs and the actions required by staff to meet the needs consistently. None of the support plans we examined were due for review. The manager and staff make good use of other health care professionals to meet peoples needs. Detailed records were available to support appointments and advice given. The manager and her staff team are doing a good job of supporting people with increased mental and physical frailty. As part of the SPARS all people have completed Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: health care assessments. We examined the storage and administration of medication in the home which showed that both areas are well-managed and do not put people at risk. Each of the care files we examined contained plans to address peoples wishes around increased mental and physical frailty. The AQAA highlights the need to develop more diverse communication methods to enable more people to understand their plans. Health was an area assessed by a recently completed quality assurance process managed by the assistant-regional director. Care Homes for Adults (18-65 years) Page 19 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this 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 able to make a complaint if they are unhappy and feel confident they would be listened to by the manager and her team. Financial procedures and staff practices minimise potential risks to people. Evidence: The service has a complaints procedure that is produced in an easy read format. We spoke to people individually about making complaints, each person confirmed they had a copy of the complaints procedure and felt that if they were unhappy they could make a complaint and they would be listened too. This was also confirmed by the expert by experience. Speaking to staff they were clear about the steps they would take to ensure someones safety if they made a complaint and the procedure to follow. Staff receive a copy of the General Skills Council codes of Conduct at commencement of employment and new staff are supported through the induction programme. For all existing staff regular updates are given through team meetings. Families are encouraged to share any concerns or complaints and these are responded to by either the manager or the service manager. HFT regularly monitors complaints and how they are managed through the use of quality management and other auditing tools. Staff training is well-organised and records showed that staff had completed training in safeguarding adults, where this training is due to be refreshed plans are in place to Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: achieve this. Each person has a financial assessment and guidelines within their support plans. This identifies the persons ability to manage their own finance and details the support staff are required to give when supporting a person with their money. Financial records were seen to be thoroughly recorded. Care Homes for Adults (18-65 years) Page 21 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides people with a comfortable, safe and friendly environment that meets their current needs. Evidence: Each person living in the home has their front and bedroom door keys. The home is a large domestic house which has been converted for its current use. A tour of the building was completed with a person that lives there. The main hub of the home is the large kitchen/diner where we witnessed people making drinks and sitting around talking. In addition to this space there is a lounge with a TV, DVD player and Stereo. All of the communal areas were decorated to a high standard and equipped with good quality furniture and fittings. In conversation with people they explained that they were asked about how the home should be decorated and the furniture supplied. We were invited to see 2 bedrooms on this occasion, 1 person said that although they had not decorated it yet, they had been able to add their pictures, furniture and other personal belongings. Visiting the other persons bedroom they explained they had chosen the colour scheme, added all of their furniture, pictures and electrical Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: equipment. The AQAA highlights that in the past year 2 of the bedrooms have been decorated. We saw all of the bathrooms and toilets. These were all decorated nicely with the downstairs bathroom being recently decorated on the request of people living in the home. The home has a dedicated laundry which provides people with a washing machine and tumble dryer. The home has gardens to the front and rear. In the front garden outside 1 of the ground floor bedrooms a person has set up a bird table enabling them to maintain their hobby of bird watching. The rear garden is well-maintained by the staff and people living in the home. To the rear of the property is a self-contained flat. At the time of the 2nd site visit this accommodation was vacant and we therefore did not inspect it. The manager explained that they plan to re-decorate it before anyone is admitted. Staff complete weekly maintenance checks around the home completing a report identifying any shortfalls. All shortfalls are then reported to HFTs maintenance department. This is a good practice as it minimises the risk of maintenance issues being missed. The home has a hearing loop system fitted to support people with hearing loss. At the time of our site visit the home was clean and tidy. We witnessed people living in the home completing tasks like hoovering. The service has a planned maintenance programme, the AQAA identified that plans for the coming year include an exit fire door being fitted in the self-contained flat in the rear garden, redecoration of a downstairs bedroom and modifications to the art room. Care Homes for Adults (18-65 years) Page 23 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. HFTs recruitment procedures minimise the potential risks to people living in the home. People living in the home benefit from a well trained and settled staff team that clearly understand peoples needs. Staff appraisals are behind schedule and this impacts on monitoring performance and setting agreed goals for the future. Evidence: HFT provide job descriptions and person specifications for each post within the service. All staff are expected to comply with the GSCC code of conduct and HFT standards. HFT has an active development and training policy in place. This training programme starts with a detailed induction programme that covers the Sector Skills Council standards. On completion of induction individual training plans are developed. HFT has designed a professional passport for staff that identifies expectations within their roles through the use of a capability matrix. Measurable targets in relation to job role and development are set annually. HFT annually makes a financial commitment to the development and training of personnel at all levels, this is reflected in a budget that is managed locally. Internal and external training expertise is accessed. The manager supplied us with the current training records for a new member of staff that showed they had successfully completed their induction and courses in: - Mental Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: Capacity Act (2005), moving and handling, contenence, fire awareness, food safety, COSHH, risk assessment, Person Centred Planning, infection control, safe handling of medication, safeguarding adults and first aid. Training records for the rest of the team showed us that a wide range of training has been completed to meet professional development and the needs of people living in the home. As identified earlier in this report organising training is the responsibility of 1 staff member, and they do this effectively. Staff turnover in the home is extremely low with only 1 person leaving since the previous inspection was completed. As a result only 1 member of staff has been employed since the previous inspection was completed. We examined the records relating to this process which showed all of the documents required by these regulations were in place. After receiving training from the manager people living in the home are involved in the interviewing of new staff. we saw evidence of people asking the candidate questions, and being asked for their opinions. At the time of this inspection all but 1 member of staff has completed at least an NVQ (National Vocational Qualification) level 2 in care. As a result a number of staff are currently completing NVQ level 3s in care. We looked at records for staff supervision and appraisal. Speaking to the manager they were open with us stating that this had been an area that needed to be improved. Records of staff supervision showed that the majority of staff 2/3 supervisions in the past 8 months, but good practice is for staff to receive supervision every 6 weeks. The manager gave their assurance that this would be addressed in the future. HFTs own quality assurance procedures identified a shortfall with staff appraisals and has set the manager a goal of completing all appraisals by July. It becomes a recommendation of this inspection report that the manager ensures that staff receive regular supervision sessions. Speaking to staff during our 2 site visits they agreed that the training provided by HFT was good and met their needs. Comments from people living in the home about the staff included, the staff are always happy, they always listen to me. Care Homes for Adults (18-65 years) Page 25 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this 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 service is managed by a highly competent manager with considerable experience in this field and this is reflected in the quality of the service being provided. HFT have a quality assurance procedure which seeks the opinions of people in the home and assesses outcomes, where shortfalls are identified goals are agreed to address them. Risks to peoples health and safety in the home are minimised through training, procedures and checks completed by staff and other professionals. Evidence: The registered manager has been in post since the service opened in May 2000. They hold both an NVQ level 4 in the management of care and a Diploma of social work. They have also completed an Open University course in mental health and mental distress to enable them to have a better understanding of some peoples. Completing this qualification was also part of their professional development. From speaking to members of the staff team it is clear that have a very good understanding of peoples needs. This is due in part to the settled nature of the team, Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: the majority of which have worked at the service since it opened. But this is also due to the training they have completed and the managers leadership. Between September and December 2008 the assistant-regional director completed a quality assurance audit. This was achieved by them seeking information from in and outside the service. Either completing interviews, observations, attending meetings and asking people (relatives, other professionals, etc) to complete questionnaires. On completing the audit they produced a report for the manager that identified good practises and shortfalls. Any shortfalls became agreed targets for the service to meet. This is a good practise and helps to improve the quality of the service being provided. Where a provider is not in day-to-day charge of the service the regulations require that someone from outside the home complete monthly unannounced visits. Records available for us to see in the home showed that these had been completed in January and April this year, but there was no evidence of them being completed between those months. it becomes a requirement of this report that this is addressed and these visits are completed regularly each month. The AQAA identifies when policies and procedures have been reviewed and manager stated that the only policy reviewed since we received the AQAA was the Human Resources policy. The manager and her team take a range of steps to minimise risks to people living in the home. We saw evidence of the following: - Every Saturday staff complete health and safety checks around the service, Water temperatures are monitored each week, Carbon monoxide is tested, the homes vehicle is checked weekly, fire equipment is checked as required, Portable Appliance Testing (PAT) was completed in May 2008. The service has a fire risk assessment that is regularly reviewed by the manager. Due to some people being hearing impaired the fire alarm has been adapted to meet their needs. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 39 26 The manager must ensure that regulation 26 visits are completed each month and copy of the completed document is sent to the CSCI. 05/06/2006 Care Homes for Adults (18-65 years) Page 28 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 39 26 The service provider must ensure that visits under this regulation are completed regularly meeting the criteria of the regulation. Failure to complete these visits is a clear breach of the regulations. 19/06/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 The manager needs to ensure that any future admission processes are thoroughly recorded and available for examination as required. The manager should ensure that the person has a contract in place that details what the service will provide and the expectations of the person. The manager should ensure that all staff receive their annual appraisal. 2 5 3 36 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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