Inspection on 28/05/09 for Erindale (1a)

This is the latest available inspection report for this service, carried out on 28th May 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Erindale (1a) 28/09/05

Erindale (1a) 05/04/05

Erindale (1a) 23/11/04

Erindale (1a) 08/06/04

Erindale (1a) 21/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Erindale (1a) Erindale (1a) Plumstead London SE18 2QQ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Peter stanley     Date: 2 8 0 5 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Adults (18-65 years) Page 2 of 29 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 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 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. 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 Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Erindale (1a) Erindale (1a) Plumstead London SE18 2QQ 02083178200 F/P02083178200 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.milburycare.com Milbury Care Services Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home 1a Erindale is one of a group of six homes for adults with learning disabilities. The homes are located in the London Borough of Greenwich and Milbury Community Services Limited is the registered care provider. This home is located in a residential area of Plumstead within walking distance of local shops and bus routes. The detached bungalow was built in 1993 and is registered with the Commission for Social Care Inspection to provide accommodation and nursing care for residents with Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 6 Brief description of the care home learning disabilities. The property consists of an open plan lounge, a dining room, a kitchen, a laundry, four single and one shared bedroom and a staff office. Adequate toilet and bathing facilities are provided to meet the needs of the residents. The fees in this service ranged from £692 to £865 at the time of this inspection. Residents pay privately for hairdressing, aromatherapy, some leisure activities, part holiday payments and personal items such as toiletries, personal clothing and personal furnishing items. Care Homes for Adults (18-65 years) Page 5 of 29 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: We looked at survey returns from those persons who use the service. We looked at the AQAA which is completed by the provider, and provides statistical and descriptive information about the service. We visited the service and completed a site visit. Checks were made on records and documentation relating to the resident and staff group, and to the day to day running of the home. We spoke with managers and staff, and observed staff interaction with residents. Care Homes for Adults (18-65 years) Page 6 of 29 What the care home does well: What has improved since the last inspection? 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. Care Homes for Adults (18-65 years) Page 7 of 29 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 8 of 29 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are being provided with the information they require, with which to make an informed choice as to the suitability of the home in meeting their needs. Prospective service users are being provided with the opportunity to visit the home, and stay overnight, before deciding whether the home is likely to meet their needs. Service users admitted to the home have been fully assessed and know that their individual needs will be met. Evidence: Prospective service users are being provided with the information that they require to make an informed choice. The home has a user-friendly Statement of Purpose and Service User Guide, these documents being written in an appropriate format for Care Homes for Adults (18-65 years) Page 9 of 29 Evidence: persons with communication difficulties. Each service user is issued with a contract. The contract sets out the homes terms and cnditions, these being observed on service users files. Greenwich PCT agree terms with the provider regarding the level of fees and conditions for placement. There has been one new admission to the home within the last 12 months. The service users file was examined. Following referral, intial assessment information had been obtained. The home arranged to visit the prospective service user in their existing placement and completed a full assessment of the individuals personal care, health, behavioural and social needs. Risk assessments had also been fully completed, these having been recently reviewed. The prospective service user is invited to visit the home and to meet resident and staff, and to stay overnight at the home, before any decision regarding placement is made. Following admission, there is a trial period followed by a review, when a decision regarding permanent long-term placement is made. This is attended by the nearest relative(s), the homes key worker and the care manager. Feedback received by relatives, care managers and service users has indicated that, generally, individuals assessed needs are being well met in this home. Care Homes for Adults (18-65 years) Page 10 of 29 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are having their personal, health and social care needs and goals set out in an individual plan of care. Care planning needs, however, to become more personcentred in its approach. Service users are being assisted to participate in decisions that affect them and their day-to-day lives in the home. Service users are being assisted to develop independent skills and lifestyle, with risk assessments being completed for activities that involve responsible risk-taking. Evidence: The inspection of service user files evidenced care plans detailing personal health care, behavioural, communication, cultural and social needs, together with information Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: regarding how needs are being addressed. Staff prepare care plans based on their knowledge of the person, and on information provided by agencies, relatives, care managers and health professionals. While care plans are providing comprehensive information about users needs, they need to become more person-centred in their format, evidencing users preferences and choices and involving service users more fully in their their preparation and review. To assist this process, staff require training in person-centred planning and care. Care plans are being reviewed at least six-monthly, with the involvement of the service user, and support agencies, with any identified changing needs being agreed and actioned. Risk assessments are reviewed and updated, with staff aiming to support service users in taking responsible, assessed risks. Individual support plans, detailing life plans and objectives, are drawn up and reviewed annually. Feedback from relatives and care managers has been generally positive. CQC questionnaires recently completed on behalf of service users by their keyworkers indicated a fairly high level of satisfaction with the home, and with the care and support being provided. Care Homes for Adults (18-65 years) Page 12 of 29 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. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are being assisted to participate fully, and to exercise choice and control in their daily routines and activities. Residents are being encouraged to maintain contact with their family and friends, and to maintain links with the local community. Residents rights and responsibilities are being respected and recognised in their daily lives. Residents are being offered a healthy and varied diet in pleasant surroundings, and are able to exercise choice with meal arrangements. Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: The philosophy of the home, as indicated in the homes Statement of Purpose, is to promote independence, assist service users to access day centres and activities, and to develop a wide range of social and independent living skills. Individual activity plans were evidenced on service users files. These indicate a fairly wide range of activities including those offered at the local day centre, which service users attend for up to 4 days a week. Service users are also assisted to access courses which develop their basic learning and social skills. Service users are encouraged to develop and maintain links with family, friends and the local community, with assistance being provided to access transport. Service users are assisted to access local shops and facilties. During the inspection one service user returned with her keyworker from a trip to the Bluewater shopping complex, having clearly enjoyed the experience. From the responses given by service users, in the CQC questionnaires, service users expressed the wish for more day trips out as a group, and for more activities to be provided in the home. One service user requested a mini bus to enable all the service users to go out together, rather than one at a time with the existing transport arrangements. Another service user expressed the wish for more trips out as a group. Service users are assisted to take an annual holiday of their choice, with support being provided as required. Service users are encouraged to participate in daily routines and to participate as fully as possible in decisions that affect them. Each service user has 1 to 1 support and consultation with their keyworker, and there are monthly group meetings involving service users and staff, where issues affecting their collective interests and welfare are discussed. Care plans, daily logs and review notes indicate that residents are able to make choices in their daily routines and activities, and that they are consulted regarding decisions that affect them. Residents are supported to take risks in developing independent skills and abilities, with a wide range of risk assessments, covering daily living and activities, being completed and reviewed at six-monthly intervals. These were evidenced on individuals personal files. There is open access to the home, and visitors are made welcome, with privacy being respected. Previous feedback from relatives indicates that the home provides a welcoming atmosphere, and that it is well regarded. Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: Inspection of the kitchen area and menus indicates that the home provides a varied and nutritional diet, with plenty of fresh vegetables and produce. Menus are provided on a six-weekly cycle, with service users being encouraged to indicate their preferences and choices. here a main dish is not to an individuals liking, an alternative option is made available. Given the difficulties with eating, for this client group, food tends to be pureed, or fed artificially. Staff operate a rota system with food preparation, with staff being required to undertake food hygiene training. The dining area in the main lounge was observed to provide a pleasant place for taking meals. Care Homes for Adults (18-65 years) Page 15 of 29 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. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Generally, the health and personal care needs of residents are being well met, and their privacy and dignity respected. However, to ensure a more comprehensive and person-centred approach to meeting health care needs, a Health Action Plan should be developed for each resident. Generally, residents are being protected by the homes medication policy and procedures. However, to ensure the safe administration of medication to residents, all staff must undertake accredited medication training. Evidence: As detailed in residents assessments and care plans, there is a high level of need in this resident group for both personal care support and health monitoring. The home has individual care/support plans in place. These detail the wide range of health care and support needs that are presented, and the actions being taken to address these. However, a Health Action Plan, involving the service user and relevant health Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: professionals) should be developed. The HAP should identify each residents health needs and wishes, and the actions required to meet these. A recommendation applies. The home maintains close monitoring of residents weight, physical and mental wellbeing, and makes referrals, when required, for professional health care and ancillary support. All residents are registered with a local health care practice, and there are close links with the local multi-disciplinary PCT learning disabilities team. Inspection of residents personal files indicated that is regular contact and monitoring of residents by relevant health care professionals, with escorted visits from the home to access GP, hospital, dental, physio, chiropody and other health care appointments. Inspection of residents files indicated that there is regular contact and monitoring of residents by relevant health care professionals, with visits/appointments being arranged. There is emphasis on providing personal care and support in a way which respects residents privacy and dignity. Whilst the layout of the home does not allow for residents to have their own ensuite facilities, staff endeavour to provide help with bathing and personal care in a way which is respectful. However, given that there are shared bathroom and toilet facilities, it can, at times, be difficult for staff to ensure privacy and provide help in a way which respects individuals preferences. The home maintains basically sound systems for the receipt, recording and disposal of medication. Blister packs are used for dispensation, with MAR sheets being maintained for all administration. A sample of MAR sheets was found to have been accurately completed. Safe systems were found to be in place for the storage and safeguarding of medication. None of the residents are able to self-administer and require assistance with taking their medication. Whilst medication policies are in place, with staff being made aware of correct procedures and practice, only one staff member (the acting manager) has completed accredited medication training. This training needs to be prioritised for all staff who administer medication within the home. A requirement applies. Care Homes for Adults (18-65 years) Page 17 of 29 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. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has an appropriate and well- publicised complaints policy and procedure in place. Residents, and their relatives or friends, are encouraged to raise any concerns that they have. The homes policies, procedures and track record indicates that residents are being protected from abuse and are living within a safe environment. A recent concern is, however, currently being investigated under the safeguarding procedures. Evidence: The home has an appropriate and well- publicised complaints policy and procedure in place. The complaints record is kept in the hall, together with the last inspection report. The home has generally had a good track record in this area, with just one complaint being registered within the last 12 months. This is a recent complaint and raises some concerns about the well-being of a service user. This is the subject of an internal investigation within the home, and is also currently being investigated under the local safeguarding procedures. The home provides robust procedures for responding to any suspicion or allegation of Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: abuse. A whistle-blowing policy is in place. POVA training is arranged for staff, with a copy of the local authoritys POVA policy being kept accessible in the home. Staff induction covers the POVA procedures, with training in abuse awareness being provided for all staff. There has been one recent concern involving a service user which is currently being investigated under the safeguarding procedures. No other allegations have been recorded, the home having had a generally exemplary record in this area. Care Homes for Adults (18-65 years) Page 19 of 29 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. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents live in a safe, hygienic and well-maintained environment, with access to appropriate and sufficient communal facilites. Residents rooms are safe, comfortable and pleasantly decorated, being suited to their individual needs. Evidence: Whilst the home was not purpose-built for this client group, the home environment offers a pleasant, homely and hygienic environment. Each resident has their own room, the rooms presenting as pleasantly furnished and arranged, and within acceptable size limits. Bedrooms seen presented as being clean, tidy and personalised with photos and personal possessions. There are no ensuite facilities in the rooms, bathroom and toilet facilities being shared between the five residents. Appropriate bathing. and moving and handling equipment are provided. The bathroom has a special bath for assisting disabled access, and a hoist to assist bathing and personal care. Hoists are being regularly serviced, most recently in May 2009. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: There is a very pleasant lounge and separate dining area with a large flat screen television. The home is generally in a good decorative state, and carpeting of communal areas presented as satisfactory. There is a pleasant, functional kitchen with plenty of fridge and cupboard space for food storage. Standards of cleanliness and food hygiene presented as being of a high standard. The home has been adapted to meet the needs of this client group, with the necessary rails and aids to assist mobility and independent living. Residents have their own special wheelchairs and there are comfortable armchairs and sofas in the lounge area. The home generally presents as being clean and hygienic. There are systems in place for controlling infection, staff being provided with handwashing facilities and protective clothing. Staff are provided with training in infection control. Care Homes for Adults (18-65 years) Page 21 of 29 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 are being supported by an appropriately trained and qualified staff group. Residents can be assured that their needs are being addressed by staff who are being appropriately supported through supervision, training and appraisal. Evidence: The staff group presently comprises of an acting manager, 4 trained nurses and 6 support workers. The staff rota indicates that appropriate levels of staffing are being maintained. Staff assist with cleaning and food preparation as well as providing support and personal care for the residents. The providing organisation has its own care bank which provides temporary staff input as and when the need arises. The home has appropriate recruitment policies and procedures in place which comply with equal opportunities. There is a system in place which ensures that all nurses who work in the home are registered with the NMC. Those staff who were present at the time of inspection presented as being caring and committed in their approach and interaction with residents. There is very low staff turnover in this home, no new staff having been recruited within the last 12 months. There is, however, pending recruitment of a new manager following the recent retirement of the previous manager. Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: Staff receive appropriate supervision from their line manager, with all staff being given opportunities for ongoing personal development through training, appraisal and delegation of responsibilities. Where any concerns are identified, these are addressed through supervision. There is an ongoing programme of staff training which covers all mandatory training and training relating to specific client needs. Recent training has included training in manual handling and epilepsy. Staff files evidence training certificates and qualifications, including evidence of NVQ attainment. 8 out of 10 staff have achieved NVQ Level 2 or above. The inspection identified the need for staff training in Person Centred Planning. This was discussed with the Operations Manager, Helen Randall. A recommendation applies. Care Homes for Adults (18-65 years) Page 23 of 29 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. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are living in a home that is generally being well-managed and run in their best interests. There are quality assurances processes in place with which to evidence that the homes providers are obtaining feedback from users, relatives and other stakeholders, and that it is monitoring and seeking to improve the quality of its services. The health, safety and welfare of residents are being appropriately protected. Evidence: The home does not presently have a registered manager, the home presently being managed by an acting manager (an acting-up team leader) with support from Helen Randall, the area-based Operations Manager for Voyage. Ms Randall advised that Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: Voyage are taking the necessary steps to try and recruit a suitable new manager. The evidence from this inspection indicates that the home has been well managed and that it is presently functioning effectively pending the appoinment of a new manager. Views expressed by residents, from CQC questionnaires, indicate that residents generally feel happy and settled living in the home, and find staff to be supportive and caring. There is a quality assurance process in place which provides feedback from residents, relatives and other parties. An annual quality assurance report (Annual Service Review and Development Plan) is published, the one for 2009 being in preparation at the time of this inspection. The Operations Manager advised that new questionnaires are being developed (using a user-friendly format) for residents at the home. The home has had up-to-date Fire Safety, Health and Safety, and COSSH risk assessments, these being evidenced during the inspection. All the necessary health and safety checks are up-to-date and no concerns were identified. There are regular fire drills and checks, and fire safety training, these being evidenced from records kept in the home. Care Homes for Adults (18-65 years) Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R 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 26 of 29 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 20 13 All staff who administer medication must undertake accredited medication training. To ensure safe administration of medication. 01/09/2009 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 6 Care plans need to become more person centred, evidencing the involvement of the service user (and/or advocate) in this process. The home should aim to provide opportunities for more group outings, and provide its own transport for this purpose. To ensure a more comprehensive and person-centred approach to meeting health care needs, a Health Action Plan should be developed for each resident. Residents would benefit from staff undertaking training in person-centred planning, and thereby consolidating a more person-centred approach to the delivery of their care. Page 27 of 29 2 14 3 19 4 35 Care Homes for Adults (18-65 years) 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 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!