Inspection on 02/03/09 for Kings Lodge

This is the latest available inspection report for this service, carried out on 2nd March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kings Lodge 19/04/06

Kings Lodge 09/01/06

Kings Lodge 11/01/05

Kings Lodge 09/09/04

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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Kings Lodge 47 Kingsway Wembley Middlesex HA9 7QP     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: Andreas Schwarz     Date: 0 3 0 3 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 32 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 32 Information about the care home Name of care home: Address: Kings Lodge 47 Kingsway Wembley Middlesex HA9 7QP 02089030952 02089029611 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) : Mr Anil Rawlley,Mr Brijendra Sinha care home 9 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 9 The maximum number of service users who can be accommodated is: 9 The registered person may provide the following category of service only: Care Home only - Code PC 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 Kings Lodge is a care home providing care and accommodation for up to 9 adults with a learning disability. Ablegrange Ltd owns the home. The home is located in a residential area near Wembley and within reasonable walking distance of two underground stations. A number of bus-routes and Wembley High Street is close by. The home is a converted semi-detached house and was first registered under the Registered Homes Act 1984 in April 1990. Accommodation for people using the service is provided on the ground and first floors; all but one of the bedrooms is single occupancy. There is parking at the front of the house and on the street; at the rear there is a good-sized garden and a building, which is the Registered Managers office, activity room and utility room. Information about fees and charges can be obtained Care Homes for Adults (18-65 years) Page 4 of 32 Brief description of the care home from the manager or registered provider. Care Homes for Adults (18-65 years) Page 5 of 32 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 unannounced key inspection lasted eight hours. We visited the home twice during this inspection process on the second day of this inspection we assessed training records and spoke to a number of care staff. We spoke to four people using the service, the manager, two relatives, one social worker and one of the directors over the telephone. The home did not return a completed Annual Quality Assurance Assessment in time to include into this report. People using the service returned three surveys and staff returned two surveys, which have been send out prior to this key inspection. We assessed care plans, staffing records and other records required to make a well balanced quality judgment about the quality of care provided to people using the service. We would like to thanks people using the service, manager, staff, relatives, etc. to be transparent and supporting us during this key inspection. Care Homes for Adults (18-65 years) Page 6 of 32 Care Homes for Adults (18-65 years) Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: We have made eight requirements during this key inspection. More update of the statement of purpose and service users guide is required ensuring prospective and current people using the service are provided with up to date information about the home. The manager must not borrow money from people using the service to pay for household bills. People using the service needing bedrails must have risk assessments ensuring their safety during the night. The home must ensure to provide a more varied menu and have people using the service involved in the menu planning. The responsible person must ensure that staff are provided with the necessary training to fully support the needs of people using the service. Regular supervisions must be provided to staff ensuring they are supported when working with people using the Care Homes for Adults (18-65 years) Page 8 of 32 service. The responsible person must ensure to send out surveys from people using the service and significant others and obtain their view about the quality of care provided. 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 9 of 32 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 10 of 32 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. The home provides a statement of purpose that is specific to the individual home and the resident group they care for and give prospective people using the service information about the home. Admissions are not made to the home until a full needs assessment has been undertaken to ensure the home is meeting peoples needs. Evidence: The home has reviewed the service users guide and statement of purpose since the last key inspection. Overall both documents are of good standard. The Commission for Social Care Inspection (CSCI) contact details have not been included in the up date, which is required. This ensures new prospective and current people using the service are provided with up to date information. The service users guide and statement of purpose is not available in a user friendly format. It is recommended to provide both documents in a user friendly format to make it available to a broader audience. We looked at assessment information of people moving into the home recently. One of the people moved in as an emergency admission, the home did not undertake an Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: assessment on admission. The home however provides a detailed care plan for the person, which is addressing is needs. We found a detailed needs assessment, which has been undertaken by the placing authority. We viewed two assessments during the previous key inspection. Assessments are detailed and information is transferred to peoples care plans. We viewed two care plan files during this inspection; all files contained a detailed needs assessment undertaken by the referring authority. People using the service were not able to tell us about the assessments. Care Homes for Adults (18-65 years) Page 12 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service and families are involved in the care planning process and their choices are included in care plans. People using the service are supported to make choices and advocacy can be accessed if independent support is required. Peoples risk is managed appropriately, ensuring people using the service are protected. Evidence: We assessed two care plans during this key inspection. Both documents are of good standard and provide detailed information in how to meet the needs and what support is required. Needs addressed are, taking of clothes during the night, showering, aggression, incontinence, etc. Family members tell us that they have been informed about the care plan and are involved by the home in reviews. The home is reviewing care plans annually involving people using the service, social worker, family, key workers and any significant others. The manager informed us that the home has introduced monthly review meetings, records of this meetings show that the person is Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: meeting with the key worker monthly to discuss the care plan and any other issues relating to the person. A picture of the key worker and co-key worker is displayed in peoples rooms. Staff have received care planning training and demonstrated good understanding of the care planning process. We spoke to three people using the service who confirmed of being involved in the care planning process together with their key worker. The manager has re-organised care planning files and issues relating to people using the service are well documented. We observed people using the service access the kitchen to make their tea, get fruit or biscuits. Staff were observed asking people using the service of what they want ands their decisions are followed. The home accessed Brent Advocacy Concern to provide advocacy for service users. A letter send by the advocacy project stated that the home is currently on the Top Ten waiting list for advocacy. We assessed peoples finances and noted that two tins were not balanced. We discussed this with the manager who informed us that she has borrowed some money to pay the milk bill for the home. People using the service have not informed about this. This practice is not acceptable and must stop. The manager also told us that she is borrowing money occasionally to residents to make personal purchases. This raises concern and the practice must not continue. We discussed this in detail with the manager who demonstrated clear understanding that the practice is not professional and reassured the CSCI, that this practice would not continue. We viewed a range of very detailed risk assessments in service users files. Staff have signed a form confirming that they have read and understood risk assessments. Staff told us that they are aware of risk assessments and gave us some examples demonstrating their understanding of risk assessments. The manager told us that risk assessments are reviewed if risks change or during the care planning process. Risk assessments viewed provide detailed information to staff in how to minimise and manage risks. One of the people living at the home is using bedrails, we did not find a risk assessment in the persons care plan and informed the manager that this is required. Care Homes for Adults (18-65 years) Page 14 of 32 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. The service has a strong commitment enabling residents to develop or maintain their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. People who use the service have the opportunity to develop and maintain important personal and family relationships. People using the service are involved in meaningful daytime activities of their own choice and according to their individual interests. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. Evidence: Three of the people using the service go regularly to day services. One of the people informed us that he has chosen the day centre on his own. We spoke to the person during this inspection and he informed us that he is very happy with the day centre Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: and is looking forward going there. People using the service are not in paid employment. We observed people using the service reading together with staff during this inspection. One of the people living in the home told us that he does not want to go to a day centre or work and is happy with the activities offered by the home. We observed people using the service going to the park during the second day of this inspection. One of the people is using a taxi independently to go to his day centre. Another person told us that he is going food shopping with the manager. Staff told me that due to staffing ratio and some people requiring 2:1 in the community it is at times difficult to access the community. The manager confirmed this, but informed us that for planned activities extra staff can be put on duty. The majority of staff employed are from the Indian Subcontinent, the manager is Caucasian, this reflects the cultural background of people using the service. Peoples families are involved in their lives. One person received a visit during the day of the inspection. We spoke to the relative who told us that they are extremely happy with the home and referred to the manager as excellent. The manager told us that one service user went for a family wedding. Another person was observed speaking to his aunt over the phone. People using the service told us that they could have visitors in their room if they choose to. We observed people using the service getting up during different times of the morning and leaving the home independently if they are able and stated in their risk assessments. The home has a keypad system and people who are safe to go independent know the number. We observed people using the service interacting with their peers and staff. People told us that this is their home and they can move around freely, which was observed during this inspection. A list of household tasks done by people using the service is displayed on the notice board and the manager told us that service users are responsible for the recycling of waste. People can smoke in the garden and a small shed is provided for cold and rainy days. The home has a menu and we observed staff cooking lunch. People using the service told us that they are happy with the meals provided and can choose their dishes. Meals provided are healthy, nutritious and well presented. The home records meals consumed by people using the service. We assessed the homes menu, which is repeated weekly. We discussed this with the manager and recommended to discuss menus weekly and provide more variety in the menu. Fruits and drinks were freely available throughout the day of the inspection. The fridge was fully stocked with a wide range of ingredients and people using the service can freely access the kitchen and help themselves. Menu planning is not accessible to all people using the service and the use of pictures is recommended. The home is providing dishes and ingredients, Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: which are culturally appropriate. One of the people requires assistance to eat and clear guidance in how to assist and puree the meals are in place. Care Homes for Adults (18-65 years) Page 17 of 32 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. People using the service are well supported to access health care services. Staff administer medication safely and people using the service are protected by staff having received medication training. Regular health care appointments are seen as important and there are systems to ensure they are not missed. The home arranges for health professionals to visit people using the service at home when necessary. Evidence: The home has detailed personal care guidelines and support guidelines for people using the service in place. Guidelines are updated if needs change. One of the people living at the home is at risk of developing pressure sores. This has been assessed using the water-flow assessment. The home has involved the continence advisor to support staff to minimise the risk of developing pressure sores. We viewed communication information for one of the people living at the home and staff is provided with information in how to read hand gestures and facial expressions. Staff have received training in manual handling and a new hoist has been purchased by the home. People using the service told us that they are supported by staff to purchase new clothes. Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: The home has established very good links with health care professionals, such a GP, Behaviour specialists, Psychiatrist, Nutritionist, Community Nurse, Psychologist, Bereavement Councilor, Continence Advisor, Speech and Language Therapist, etc. We observed the manager arranging appointments for people using the service to visit health care professionals. One of the people was supported by the home to have a growths removed. The person told us that this has helped his self-confidence and selfimage. People are supported to visit the dentist, optician, podiatrist, etc. All visits to health care professionals are clearly recorded. The home has a copy of the Royal Pharmaceutical Societies guidance of Medication administration in Care Homes in the medication file. The medication policy has been removed by a member of staff to study for her medication training. All staff administering medication have received medication training. The home does not have controlled drugs. The Medication Administration Sheets (MARS) had no gaps. We spoke to one member of staff who demonstrated good understanding of the side effects of medication administered to people using the service. The medication cupboard was clean and well organised. Care Homes for Adults (18-65 years) Page 19 of 32 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. The service has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home. The home understands the procedures for safeguarding adults and will attend meetings. Evidence: The home has a complaints procedure in place, which has been send to relatives. The complaints procedure is displayed on the noticeboard and people using the service confirmed in surveys that they know whom to complain to if they are not happy. The home did not receive a complaint since the last inspection. People using the service and relatives spoken to are happy with the care provided and have no complaints about the home. The home is recording compliments. Letters received from relatives state. As a relative of one of the service users in Kingslodge I have to say the care is excellent. XXX has improved so much since the new manager has started. Staff have attended safeguarding adults training and six out of ten staff have National Vocational Qualifications in Care. One of the mandatory units of this award is addressing safeguarding adults procedures. The home has local and funding authorities safeguarding adults procedures in place. The home did not make a safeguarding referral since the last inspection. Staff spoken to demonstrated good understanding of safeguarding procedures. Care Homes for Adults (18-65 years) Page 20 of 32 Care Homes for Adults (18-65 years) Page 21 of 32 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. People using the service live in a nicely decorated, comfortable and homely environment. The home is clean and free of offensive odours. Evidence: The manager showed us around the home. The home has changed around the layout in the lounge and moved the dining area towards the window. The seating arrangements are much more homely and are set up in u-shape. The manager has created a little office space in the corner of the lounge, which allows staff to do day to day administrative work. People using the service told us that they have no problems with the office space in the lounge. To divide the office space from the lounge, we recommend to put up a curtain. This ensures people using the service have privacy in their lounge. The manager has purchased pictures and ornaments, which are on walls throughout the home, creating a homely and comfortable atmosphere. The hallways have recently been decorated and workman did some repair and decoration work during the second day of this inspection. The home has a Annexe in the garden and the manager is in the process of creating an activity room for people using the service. We viewed this room, which has games, toys, dart board, snooker table, etc., in place. The manager is planning to create a more sensory environment, once she secured funding. People using the service told us that they use the room and are happy with it. Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: The kitchen has been completely refurbished, new cupboards, appliances and utensils have been purchased. We viewed two rooms during this inspection. Rooms are nicely decorated and personal things are displayed. The home has currently one vacancy, we viewed this room, which is nicely decorated. The home was clean and free of offensive odours. The utility room is located in the Annexe and the washing machine and dryer is in good working order. The home stores cleaning materials in the sluice room, which is clean and tidy. People using the service told us that they are very happy with their home. We feel that the home is comfortable and homely, which is an improvement since the last key inspection. Care Homes for Adults (18-65 years) Page 23 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is aware that there are some gaps in the training programme and plans to deal with this. The service has a recruitment procedure that meets statutory requirements and the National Minimum Standards. Evidence: The rota shows that two staff are on duty during the morning, afternoon and one during the night. The manager is available during the day, but will come in on weekends or stay later in case of emergency cover. Staff told us that the cover provided does not enable people using the service to access community based activities as they choose. The home has provided the same staff cover for the past four years, but service users vacancies have reduced. We strongly recommend to review the current staffing ratio and provide more staff ensuring people using the service are able to attend their chosen activities. Staff is attending NVQ training and currently six out of ten staff hold or work towards their NVQ in Care Level 2 or above. We assessed four staffing files, all relevant documentation such as references, application form, proof of the right to work in the United Kingdom, Enhanced Criminal Records Check (CRB) are in place and staff confirmed of having to provide documentation to obtain these. People using the service told us that staff visited the Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: home prior of being offered a post and are very happy with the staff employed by the home. We viewed an up to date training plan, staff have attended Safeguarding training, manual handling training, medication training, etc. The manager is currently planning for food hygiene training, Infection control training, Fire training, Health and Safety training and Epilepsy training. She is in discussion with the directors to provide funding for these mandatory training sessions. Other planned additional training sessions are Loss and Bereavement and Person centred Planning. Staff told us that they have received training from the Continence Advisor. Staff told us that the new manager is very supportive and is always available for help and listens to problems and difficulties staff may experience. The new manager has provided supervisions, but records show the minimum requirement has still not been met. This could be due to the high volume of work and all other work the manager has implemented since commercing her post at the end of April 2008. The manager reassured us that she will continue to improve the service and is planning to continue to provide planned supervisions ensuring the minimum requirements of six planned supervisions are met. Care Homes for Adults (18-65 years) Page 25 of 32 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 home is managed by an experienced and enthusiastic manager, who works very hard to improve the outcomes for people using the service. People using the service are involved in the running of the home, but should have better opportunities to give their views about the home and the care provided. People using the service are protected by Health and Safety procedures and policies from accidents and emergencies which could arise, such as fire, gas leak, etc. Evidence: A new manager has started in April 2008. Feedback received about the manager from people using the service, staff, relatives and social workers was very good. Relatives referred to the manager as excellent, one social worker contacted us a few months prior to this inspection telling us that we must visit the home to see the improvements put into place by the new manager. People using the service told us that they like the new manager and are very happy with her. And staff told us that the new manager is very supportive and always available. The new manager has a wide range of experience within the care sector, ranging form childcare to managing day centers for Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: people with learning disabilities. The manager has NVQ Level 3 and is currently in the process of starting her NVQ Level 4 and Leadership and Management Level 4 Award (this qualification has replaced the Registered Managers Award). The manager is very enthusiastic and eager to implement more changes to improve outcomes for people using the service. The manager told us that her registration documents with the CSCI have been returned and she reassured us that she will reapply by no later the 01/04/09. The manager informed us that she did not undertake stakeholders questionnaires to obtain information for the annual development plan. We assessed a business plan, which does address changes planned for the next twelve months, but each objectives do not have a person accountable for achieving the objective and the timescale in which the objective should be met, we discussed this the manager. The last residents meeting took place in January 2009 and was attended by all people using the service. The last staff meeting was held in January 2009. The manager has reviewed all policies and procedures and re-organised them completely. Policies and procedures are now easy to access and to find. Staff told us where to find the policy folder and informed us that they have read policies for their NVQ. Record keeping has improved and all records have been re-organised and kept in a lockable cabinet, which can only be accessed by people authorised to do so. We assessed Health and Safety certificates such as Portable Appliance Test (Expires 22/09/09), Landlords Gas Certificate (Expires 25/02/10), etc. We found all other required certificates in order. Fire records are up to date, we recommend to review the fire risk assessment. The home has a wide range of Health and Safety policies in place and Health and Safety checks are undertaken monthly. Care Homes for Adults (18-65 years) Page 27 of 32 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 28 of 32 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 1 6 The home must up date the statement of purpose and include changes such as the new CSCI contact details. This ensures prospective and current people using the service are provided with up to date and current information about the home. 01/04/2009 2 7 16 The responsible person must 01/04/2009 ensure that staff do not borrow money to people using the service out of their own personal finances. This ensures a clear professional relationship and service users finances are managed appropriately. 3 7 16 The responsible person must 01/04/2009 ensure that service users finances are only used for personal expenditures and not for household bills. Care Homes for Adults (18-65 years) Page 29 of 32 This ensures that services users finances are managed properly. 4 9 13 The responsible person must 01/04/2009 provide a risk assessment if bedrails are provided. This ensures people using the service are safe and do not sustain injuries when using bedrails. 5 17 16 The home must provide a more varied menu. This ensures that all people using the service have an opportunity to choose meals they like. 6 35 18 The responsible person must 01/05/2009 ensure that adequate funding is released for mandatory training. This ensures only staff appropriately trained supports people using the service. 7 36 18 The responsible person must 01/05/2009 ensure that all staff receive their regular supervisions. This ensures staff are fully supported to improve the outcomes for people using the service. 8 39 21 The home must send out regular stakeholders questionnaires. This provides the home with the necessary information of what improvements are Care Homes for Adults (18-65 years) Page 30 of 32 15/04/2009 01/05/2009 requested by people using the service and any significant others 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 1 We recommend to provide the statement of purpose and service users guide in user friendly format. This enables people who are unable to read to access the documents. We recommend to involve all people using the service in the planning of menus and suggest pictures, symbols, etc. to do this We recommend to hang up curtains to divide the office space from the lounge, providing people using the service with more privacy. We strongly recommend to review the current staffing ratio and provide more staff ensuring people using the service are able to attend their chosen activities. We recommend to provide clear information of timescale and accountability in achieving business plan objectives set by the home for the coming year. The fire risk assessment should be reviewed annually ensuring people using the service are continue to be safe if there is an outbreak of a fire. 2 17 3 28 4 32 5 39 6 42 Care Homes for Adults (18-65 years) Page 31 of 32 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. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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