Inspection on 05/08/09 for 44 Blyford Road

This is the latest available inspection report for this service, carried out on 5th August 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

44 Blyford Road 20/09/06

44 Blyford Road 25/01/06

44 Blyford Road 24/08/05

44 Blyford Road 21/02/05

44 Blyford Road 04/08/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

15 Bramble Close

Extracts from inspection reports are licensed from CQC, this page was updated on 24/11/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 44 Blyford Road 44 Blyford Road Lowestoft Suffolk NR32 4ST The quality rating for this care home is: three star excellent 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: John Goodship Date: 0 5 0 8 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. They reflect the things that people have said are important to them: 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 © (20092008) 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: 44 Blyford Road 44 Blyford Road Lowestoft Suffolk NR32 4ST 01502531007 F/P01502531007 karen.smith@mencap.org.uk www.mencap.org.uk Royal Mencap Society care home 6 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) : Number of places (if applicable): Under 65 Over 65 6 2 2 0 learning disability physical disability Additional conditions: Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 30 A bit about the care home The bungalow is situated in north Lowestoft in a pleasant residential area. There are some shops close by. It was purpose built for 6 people with learning disabilities. The home was extended and refurbished in 2003 to offer more spacious accommodation for two individuals with physical disabilities, widening all the doors in the existing building, and lowering all light switches and plug sockets to wheelchair height. A third person with physical disabilities was admitted in March 2004. The building is owned by Orbit Housing Association. The service is provided by Mencap. The fees currently charged range from £334.00 to £1063.00 per week. Care Homes for Adults (18-65 years) Page 5 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: three star excellent 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 Care Homes for Adults (18-65 years) Page 6 of 30 How we did our inspection: This is what the inspector did when they were at the care home We visited the home on a Wednesday afternoon and we were there for four hours. We spoke to the manager and the staff on duty. We toured the home. We spoke to those residents able to express themselves to us. We looked at care plans, staff records, training records and safety checks. We sent out a questionnaire to residents and to staff. Five residents filled them in, with help from staff. Six staff replied and one relative. We have used the answers to the questions and any comments in our report. The manager had to complete an Annual Quality Assurance Assessment to tell us about the home and how it improving or maintaining its standards. What the care home does well No one comes to live in the home without a very thorough assessment to make sure that the home can meet their needs, and to give the person time to see if it is where they want to live. The home is purpose-built to provide enough space and special equipment to meet the needs of the residents. Care Homes for Adults (18-65 years) Page 7 of 30 Staff and residents get on well with each other. Staff know residents wishes and likes and dislikes. The care plans are written as if the resident had written or spoken them. Residents are able to keep in touch with their families, and the staff support them to visit them. What has got better from the last inspection The garden has been tidied up and a garden contractor brought in to keep it like that. Residents now have something more pleasant to look at and more attractive to enjoy in good weather. The upgrading of the assisted bathroom has been completed. This has made it safer and more hygienic to use. Risk assessments are now written with symbols and pictures to make them more helpful to residents. Pictures have been added to other things such as the meal planner,and health action plans. All residents now have their own bank account. They have to be present whenever a withdrawal is made. This helps to involve them more with their finances and makes the account more secure. Care Homes for Adults (18-65 years) Page 8 of 30 What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact John Goodship 33 Greycoat Street London SW1P 2QF 02079792000 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 Care Homes for Adults (18-65 years) Page 9 of 30 line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 10 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 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can expect that the home will assess their needs and the suitability of the home for them, and that they will have an introductory period to test that they will like living there. Evidence: The service user guide had been developed with photos of the home and its facilities, and pictures of various activities of daily living. It described in easy read format how to complain, what the house rules were, fire precautions, confidentiality (what happens to information about you), who can see your files, and residents rights under the Mental Capacity Act. A new resident had been admitted to the home in October 2008. In their file was the application form, the needs assessment, developed from a visit by the manager to their home, and also drawing on information from the Compass report from Social Care Services, and a visit to Blyford Road by the prospective resident. The AQAA told us that this resident and their family were happy with how things were going. The individual placement contract for residents were in their files. Each resident also had a copy of the Mencap terms and conditions of residence. There was evidence that Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: new residents lived in the home for a trial period at the end of which a review was held with all parties including the funder. Care Homes for Adults (18-65 years) Page 13 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect the home, and their daily lives, to be run according to their needs and wishes, with the development of independence through planned risk-taking. Evidence: We examined the support plan for one resident, and looked at review records, and observed how staff supported this person. Support plans were person-centred, that is, each area of need and preference was written from the point of view of the resident, in the first person.There were risk assessments for activities inside and outside the home. For this resident, they covered areas such as bathing and showering, doing my packed lunch and how I want to be supported at night. Other plans included transferring from wheelchair to armchair and to bed, using the kettle to make a hot drink, and risks associated with a resident who suffered from epilepsy. In all cases there was guidance for staff on supporting residents so that the risks were minimised without reducing the residents choice of activity. These plans and risk assessments were reviewed every six weeks. The AQAA told us that key workers who led the reviews brought them to staff meetings to help identify any changing needs. The manager told us that risk assessments had been updated in the last year with pictorial Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: symbols to make them more accessible to the resident. The manager stressed to us that the ethos of the home was to enable residents to do things they wanted to do safely, not to prevent them doing them. The assessments appeared to reflect residents wishes and covered a wide range of activities according to each residents abilities and wishes. Staff signed to confirm that they had read the assessments. All residents had been reviewed by Social Care Services to assess whether each resident was correctly placed at Blyford Road, or if their needs could be met more appropriately in an alternative residential setting or in supported living accommodation. All the reviews were held with the resident apart from two who chose not to attend. Relatives were invited to the reviews. All the reviews commented that the home was very well managed, and that the paperwork required for the review was kept in good order. All the survey forms from residents told us that they made decisions about what they did each day, in the evening and at weekends. One resident said that the staff let me choose what I want to do, involve me in decisions, eg where I want to go on holiday, who I want to go with. They let me choose what I want to wear, what I want to eat and support me outside the house, shopping etc. Care Homes for Adults (18-65 years) Page 15 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to be given many opportunities to choose how to spend their time, as a group, and individually. Evidence: All residents had a planned programme of day care during the week, either at home or at an external day service. Five residents attended local authority centres, and one also attended a Mencap day service. There had been some doubt about how long one resident, who was over sixty-five, would be allowed to continue at their centre. However they had been supported by staff to attend another day care centre that better offered the activities they wanted. This was important as the resident the time spent at the centre to be going to work. This view was important to them as it gave them a direction and purpose. Two residents were taken to spend the day with a relative. The newest resident was supported by the Mencap Community Support team for three days a week, and attended a Crossroads drop in centre on one day. Residents took part in a variety of leisure activities: inside the home, such as listening Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: to their own tapes, watching television as a group or in their own room, helping with cooking and gardening; outside the home, such as going to shows, shopping and bowling. Some also participated in activities organised by SCOPE, Club 85 and the local Gateway Club. The manager told us that staff tried to find out what leisure activities residents would like to take part in including holidays. All of them had been or were booked to go on holiday. Some had gone to holiday centres in Skegness and Cheshire, and two had gone to centres locally. Usually no more than two residents went together, supported by staff. Daily records contained full information for each resident on their activities, outings, health matters, and other aspects of each day. There was a list in the kitchen giving staff information about the preferences of residents. Under each resident, it listed requests in the first person such as: Please dont give me X and I prefer breast meat to leg meat. We had seen on previous visits that residents were supported to help with aspects of meal preparation.The menu was varied and nutritious, and there was plenty of fruit in baskets for residents to help themselves. The evening meal was taken in the dining room. The manager told us that one resident had lost a close relative earlier this year. They were supported to go to the funeral which they wanted to do. We spoke to three residents in the lounge when they came home from day centres. All were happy to talk with the support of staff to make sure we understood what they were saying. They all appeared to be happy living at the home. Some told us about their holidays. There was a friendly interaction between staff and residents. A relative told us that the staff looked after their family member well. A staff member told us that they felt the home had a warm and friendly atmosphere. 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. Residents can expect their health needs to be identified, monitored and appropriate action taken. They are protected by the homes training and administration policies for dealing with medicines. Evidence: Each care plan contained an individual Support Plan written in the first person, to reflect the point of view of the resident. Examples were: If I fall down and am unable to get up....., If I cut myself or hurt myself when I have a shower....., followed by clear instructions for support workers on how to support without reducing dignity or preventing independence. Each resident had a health care action plan in pictorial format, which not only identified physical needs and actions to take, but also encouraged people to be more aware of their health needs. The AQAA told us that staff supported residents to attend appointments using the homes transport. The district nurse had encouraged a resident regarding taking their medication in a way that suited them. Staff had put together a pictorial health plan which reflected their choice. We noted from the records that health concerns were reported promptly to the health Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: professionals. The AQAA told us that the staff had asked for advice and support from the community nurse regarding a residents epilepsy. The nurse continued to be very supportive and had helped complete support plans for this part of the residents care.This gave staff clear guidance on how to support the resident. Another resident was on the breast-screening programme. One resident had had dental work done in the local hospital. A care plan showed that body maps were used whenever staff noticed that a resident had a sore patch or bruising. The medication records were examined. It was good practice that there were medication profiles in the front of each medication administration record sheet giving explanatory information on each prescribed drug. Tablets were administered from blister packs which were stored by name and time of day. The rear of each sheet was used to record when medicines marked as PRN (as required) were administered and why. It was noted that bottles were dated when opened. There were no gaps in signing for medication administered on the record sheets. Staff who administered medication had been trained on the Mencap Working safely with medicines distance learning course. They were then given annual assessments to ensure their continued adherence to proper procedures. Evidence was seen in the training record. A daily check was done to see that all medications had been given, signed for and removed from the blister pack. In two cases, medication was being taken with food. There was a letter from the GP supporting this, because the residents could not take it as a capsule.The manager told us that it was not considered covert administration as the residents were aware of it being done. There was no consent in the care plans from the resident or relative for this method of administration. 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. Residents can expect their concerns and complaints to be dealt with properly. They can expect that staff will be properly trained to protect them from abuse. Evidence: The home followed the Mencap Complaints policy and procedure. A poster was displayed in the home explaining the policy to residents in pictorial format and clear lettering. All the residents told us in their survey that knew how to make a complaint. No formal complaints had been made to the home or to the Commission in the previous twelve months. We saw records of staff training in the recognition of abuse, and the action they must take. Staff signed that they had read and understood the homes Safeguarding manual. Staff knowledge was refreshed annually through the use of the Suffolk County Council e-learning programme. The manager had also completed a Train the Trainers course. We discussed with the manager the handling of a safeguarding referral when money had been muissing from a residents cash box. The home had followed the proper procedures and the police had been informed. The manager also reported the loss to the Commission. The home had a system where staff coming on duty checked all cash tins at handover, and signed that they had done so. Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: We checked the cash for one resident chosen at random. The books showed proper receipts and records with daily handover checks, and regular checking by the manager. Allowances were recorded as paid into the bank, and bank statements were correct. The AQAA told us that all residents now had bank accounts in their own name, something which the home had been trying to achieve for many years. This now meant that each time money was withdrawn from the bank, the account holder had to be present. This had enabled staff to support all residents to use the bank. One resident had been on a twelve week Finance Awareness course at their day centre. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to live in a purpose-built home suited to their needs. Evidence: A tour of the building showed that there had been no change to the individual and communal facilities since the last inspection when all the standards were examined and were met. The kitchen had been upgraded by the landlords, a Housing Association, with new units, flooring and improved layout. The kitchen was clean and tidy. Items in the fridge were covered and dated. Temperatures were recorded regularly. The bathroom with a ceiling hoist had had a Malibu bath installed to make it easier and safer for residents to bath. The work to complete this room had been required at the previous inspection and had now been finished. There was no agreement yet with the landlord on paying for on-going maintenance of the bathrooms. The secure garden had been better maintained since the previous inspection as the home now had a contract with a maintenance firm. However it was not yet completely accessible to those in wheelchairs. The manager told us that they were investigating sources of funding for this. Care Homes for Adults (18-65 years) Page 22 of 30 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. Residents can expect to be supported by trained and competent staff who have been recruited to protect their safety. Evidence: Staffing levels were determined by the daytime programmes of the residents. There were four staff programmed on each morning to cover getting up and having breakfast, and three in the afternoon and evening. At weekends, the home was fully staffed all day. There were no vacancies, although the manager was waiting to receive a Criminal Records Bureau (CRB) certificate before a new person started. The AQAA showed that there was a low turnover of staff. One person had left in 2008, but their hours had been partly covered by existing staff increasing their hours. We examined the file of a staff member. This contained all the recruitment documentation and identity checks required. The CRB had been received prior to the person starting work.The file also contained training certificates, and induction programme. Staff training was organised through the providers training programme. Training records were kept in each persons personal file. Staff were up-to-date on the routine programmes such as moving and handling, fire procedures, food hygiene and Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: medication. Staff confirmed that they had received training in adult protection. 14 of the 16 staff had achieved NVQ Level 2 or above. The schedule for staff supervision sessions was displayed on the office wall. However the manager explained that these were taking place but were not up-to-date. In addition all staff underwent an annual appraisal. This schedule too was displayed on the office wall. A staff memebr told us that the staffing levels were sufficient for the current needs of the residents. They thought that the training provided was very good and kept them up-to-date. They had recently attended sessions on the Mental Capacity Act, the deprivation of liberty safeguards, and adult safeguarding. Staff were observed to interact well with the residents. They were able to communicate with them all. This was evident either by verbal responses or by nonverbal signs such as smiling and nodding. Staff were knowledgeable about the needs of residents and their likes and dislikes. Residents said in their surveys that staff always treated them well. 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. Residents can expect that the home will be run in their best interests, with their health and safety protected. Evidence: The manager was registered with the Commission and was experienced in the care of this client group. She had completed her NVQ Level 4 and had achieved the Registered Manager Award.The deputy manager had also obtained Level 4. Several staff told us that they all worked well as a team. One said we get excellent support from our manager and deputy manager. A survey had recently been sent out to relatives, called the How we support your family member survey. The results shown to us expressed the relatives satisfaction with the care received. Regular monthly visits were paid by the area officer who completed a report, which also met the requirements of Regulation 26. These were available in the home.These reports described discussions with residents about their views of the home, and with staff about their training and development. Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: Each What we do well section in the AQAA had been completed using standard Mencap statements about the values and policies of Mencap. These did not tell us anything about this particular home. However the manager had used the other sections to tell us about what had happened in the home in the last year and what plans they had for improvements. Overall the AQAA told us that what the home could do better was to continue to involve residents in the running of their home and to pay regard to ideas they may have. The manager usually held staff meetings at six weekly intervals, and residents meetings when there was a topic to talk about. This was usually the Christmas arrangements, or decisions on where residents wanted to go on holiday. Health and safety checks were listed on a chart in the office, showing when they were due, either weekly or monthly. Checks included fire safety, hot water temperatures and electrical appliances. All were up-to-date. The fire log showed that there were regular maintenance checks on fire equipment. The fire alarm was tested weekly with a practice evacuation twice a year. The home abided by Mencap policies and procedures. Nationally Mencap had a process to involve users in the review and development of policies although none of the residents of Blyford Road were involved in this. There were no residents subject to a deprivation of liberty authorisation. Although the manager had received training in this area, the home and the provider had not yet issued a policy and procedure for assessing potential referrals. We recommend that these are developed and assessments made as soon as possible. This would protect the rights of the residents under the Mental Capacity Act. The manager told us that the provider was planning a service restructuring for their services in Lowestoft. The CQC had not yet been formally advised of these changes. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes  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 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 Description 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 Description Timescale for action 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 3 24 27 40 The garden should be made accessible to all residents. Agreement should be reached with the landlord concerning paying for the maintenance of the bathrooms. The provider should draft appropriate policies and procedures to meet their obligations under the Mental Capacity Act, for the protection of residents. 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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