Inspection on 06/08/09 for Rivacre House

This is the latest available inspection report for this service, carried out on 6th 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

Rivacre House 14/08/06

Rivacre House 28/11/05

Rivacre House 26/04/05

Rivacre House 18/11/04

Rivacre House 10/06/04

Rivacre House 13/01/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Rivacre House 47a Seymour Drive Ellesmere Port South Wirral Cheshire CH66 1LZ     The quality rating for this care home is:   three star excellent 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: Wendy Smith     Date: 0 6 0 8 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 28 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 28 Information about the care home Name of care home: Address: Rivacre House 47a Seymour Drive Ellesmere Port South Wirral Cheshire CH66 1LZ 01513569299 01513552693 glynnorman@makingspace.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Making Space care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia: Code MD. The maximum number of people who can be accommodated is: 12. Date of last inspection Brief description of the care home Rivacre House is a purpose-built care home for people who have mental health needs. It was opened in 1992 and is run by the charity Making Space. The home is a twostorey building, located within a mile of Ellesmere Port town centre, and close to local shops and other facilities including a bus stop and a railway station. The home has twelve single bedrooms, four on the ground floor and eight on the first floor. There is a large lounge and dining area and a separate conservatory on the ground floor, and a smaller kitchen and lounge on the first floor. 12 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 28 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 peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is three stars. This means that the people who use this service experience excellent quality outcomes. We (the Care Quality Commission) visited Rivacre House unannounced on 6 August 2009 as part of this inspection. One inspector carried out the visit. During the visit we spoke with residents and staff to find out their views about the home. We walked round the building to see all the communal areas and two of the bedrooms. We checked records kept at the home and spent time talking with the home manager. We also looked at any information that we had received about Rivacre House since our last key inspection there. Before the inspection the manager was asked to complete a questionnaire to give us up to date information about the service. Comments cards were sent out for members of staff and people living at the home to give us their views of the service. Care Homes for Adults (18-65 years) Page 5 of 28 We made a short visit to Rivacre House on 28 November 2008 as part of a CSCI study to satisfy ourselves that nothing had changed and that our judgement that the home provides excellent quality outcomes for the people who live there remained valid. We found this to be the case. Care Homes for Adults (18-65 years) Page 6 of 28 What the care home does well: What has improved since the last inspection? What they could do better: We have recommended that the manager check that the controlled drugs cupboard meets the requirements of the Misuse of Drugs Act (1971) and replace it if necessary. Written guidance should be provided for staff about when medicines prescribed as required should be given, to ensure a consistent approach. Consideration should be given to employing an extra member of staff so that holidays, training and sickness can be covered by someone who knows the home and the people Care Homes for Adults (18-65 years) Page 7 of 28 who live there. This will help to provide continuity of care for them. 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 8 of 28 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 28 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. There have been no new residents at Rivacre House since 2003 but there is plenty of information available about the home, how it works and who it is for, that would help people to decide that it would be the right place for them to live. Evidence: Twelve people live at Rivacre House, nine men and three woman. Their ages range from 40 to 75. They all require support due to having enduring mental health conditions. In the annual quality assurance assessment, the information we asked for before our visit, the manager told us that all of the people who live at the home have a statement of terms and conditions relating to their residency, and appropriate contracts. There is information available about how the home works and who it is for, called the service users guide and statement of purpose. Other information, including inspection reports, are freely available in the entrance hall. There have not been any new residents since 2003 and some people have lived at Rivacre for 17 years. The manager considers that some of the people who live at Rivacre could live a more independent lifestyle but there is currently nowhere suitable Care Homes for Adults (18-65 years) Page 10 of 28 Evidence: for them to move on to. Making Space is considering buying a smaller property where people could be more independent but continue to receive support from staff as needed. There is a waiting list for places at Rivacre. Care Homes for Adults (18-65 years) Page 11 of 28 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. The people who live at the home are supported so they can make their own decisions and contribute to the plans for their care. Evidence: Key workers have developed and agreed an individual care plan with each resident. These now include a star recovery for each person to identify appropriate support for future development towards their individual goals. Residents are fully involved in their own care planning through the planning and review process. A confidential video diary records their wishes, aspirations and decisions and this is updated each year with the home manager. Due to people living at the home for a long time their care plans have become very lengthy. Daily notes are recorded which helps staff to see what peoples daily progress is. Risk assessments are in place and these include clear management strategies to address issues including alcohol consumption and people looking after their own medication. Residents are involved in their own relapse and behaviour management Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: plans and these have proved successful in helping people to stay well. Resident meetings are held regularly and their comments and suggestions are acted upon where appropriate. Rivacres policies and procedures are freely available to residents, and they are able to comment on these during meetings. A head office representative from user involvement attends some of the meetings. This showed us that the organisation and the staff take the views of the people who live at Rivacre seriously to help plan developments at the home. We received nine completed questionnaires from people who live at the home. In reply to the question Do the care staff and managers listen and act on what you say?, six people replied always, one replied usually and two sometimes. In reply to the question Do you make decisions about what you do each day?, six people replied always, two usually and one sometimes. All replied yes to the question Can you do what you want to do?. One person wrote I have been waiting for somewhere else for a long time 5 years I would like to live in a flat or house or bungalow if one comes available or a bedsit and we spoke with her about this during our visit. We also discussed this with the manager who said that unfortunately this was not a realistic option for this person at present due to her physical and mental health problems. Another person wrote The home looks after all the residents and do things very well, and a third person wrote Staff listen to me. There are individual arrangements for supporting people with personal spending money. Three people are fully able to manage their own money, nine people receive a personal allowance every two weeks via the home manager. People receive different amounts depending on their age and how their care is funded. Personal savings are put into individual bank accounts. The manager keeps good financial records so that all money kept at the home is properly accounted for. Residents do not pay extra for anything within the home, just for their own personal belongings. Care Homes for Adults (18-65 years) Page 13 of 28 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. The people who live at the home are encouraged and supported so they can use a wide range of leisure and educational facilities in the community. Evidence: People who live at the home are encouraged and supported to develop and maintain their own interests in the community. They make good use of local community resources such as the leisure centre, cinema and swimming baths, as well as cafes and pubs. Two people go to college three days a week and four go to day centres. One person is a member of a local gym and three go to a Wednesday night club. Two people are going on holiday to Spain this year and one to Blackpool. Other people are supported to go out for day trips to places of their choosing. One of the people who lives at Rivacre loves shopping and her key worker takes her on shopping trips to Liverpool. Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: The manager told us that they are looking for work placements for some people, with help from an organisation Chapter but this is difficult to achieve. People can come and go as they please, but are asked to tell a member of staff when they are going out. A board shows who is in and who is out. Staff know peoples usual patterns and may be concerned if people are out for longer than usual. All of the people who live at Rivacre go out regularly and only one person needs a member of staff to go with them. People can get up and go to bed when they want. If they are staying out after 10pm they need to let the member of staff who is sleeping in know this to make sure that they can return to the home safely. Residents are also encouraged to develop independent living skills such as cooking and housekeeping. They have been given instruction about food hygiene so that they are able to use the kitchen safely. Residents are responsible for making their own breakfast, for their own laundry, and for keeping their bedroom clean and tidy. Each person has support from the staff, which varies according to their needs and abilities. Most people have at least one family member who is involved in their day to day life. There is unrestricted visiting for family members and friends and they are invited to join in activities and outings. Staff and residents have good relationships with their neighbours, some of whom support functions held at the home. Care Homes for Adults (18-65 years) Page 15 of 28 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. Staff at the home are very knowledgeable about the support needs of the people living at Rivacre and records are thorough so people living at the home receive the support they need with all aspects of personal and health care. Evidence: Routines are flexible with regard to getting up, going to bed, and mealtimes, and individual preferences are well documented. At present no-one needs assistance from staff with personal care and all are mobile and able to take a bath or shower without assistance. However some people require encouragement and prompting to maintain their personal hygiene and appearance. Staff provide flexible support to maximise peoples privacy, dignity, independence and control over their lives. The staff we spoke with had all worked at Rivacre House for several years and showed a detailed knowledge of each persons illness, and what signs to look for that may indicate a relapse of their mental heath. Details of peoples health care needs are in their care plans. Residents are supported to make and keep medical appointments and staff accompany them if this is the residents wish. Each person has an annual review meeting with their medical consultant and community mental health nurse. People Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: also have access to community healthcare services. Two people have received advice from a continence advisor and are able to manage continence problems independently. A senior member of staff takes lead responsibility for the management of residents medicines. Medications are stored securely; however the manager needs to check whether the cabinet used to store controlled drugs meets the requirements of the Misuse of Drugs Act 1971. Good administration records are kept. Quantities are checked at each staff hand-over. These steps help to make sure that peoples medications are handled safely. A small number of medicines are prescribed to be given as required. It is recommended as good practice to provide written guidance for staff about when these items should be given so that there is consistency of administration. Residents who are able are encouraged and supported to look after their own medication. At the time of our visit two people were doing this, one with weekly packs and one person with a daily supply. Risk assessments and consent are recorded to show that any risks to do with this had been considered and guidance provided to make sure this system was safe for both people. Care Homes for Adults (18-65 years) Page 17 of 28 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. There are clear policies and procedures about safeguarding and complaints so that people who live at the home know how to raise their concerns and are protected from abuse. Evidence: There is an organisational complaints policy and procedure and they are displayed in the home. They include the timescale for responding to complaints and details of how to complain and to whom. There is also a suggestions box in the foyer for anyone to access. An advocacy service is readily available for the people who live at the home and they may use this service to express any concerns or complaints. One complaint was recorded in 2008. This was from resident. Full details were recorded and following investigation the complaint was not upheld. No complaints have been recorded in 2009. Staff are trained about safeguarding vulnerable people and there are company policies and procedures relating to abuse and whistle blowing. This helps to make sure they know what to do to protect people living at the home from harm or abuse. There are no current safeguarding adults issues at Rivacre House. The nine residents who filled in CQC surveys all indicated that they would know who to speak to if the were not happy and know how to make a complaint. Care Homes for Adults (18-65 years) Page 18 of 28 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. Rivacre House is well maintained so that it is a safe, clean and homely place for people to live in. Evidence: The exterior of the house is well maintained and fits in with the local community. There is a pleasant and well kept garden at the back of the house. The grounds are maintained by a contractor throughout the year, and some residents also enjoy helping in the garden. The inside of the home is comfortable and well maintained. Communal areas are in good decorative order and well furnished. The main lounge and dining room are on the ground floor, with a smaller lounge and kitchen area on the first floor. There is a conservatory off the main lounge which used to be a smoking area but is now nonsmoking so that everybody who lives at the home can enjoy using it. A shelter has been provided in the back garden for people who wish to smoke. There are four bedrooms on the ground floor and eight on the first floor. People who do not have good mobility need to have a room on the ground floor as there is no lift. We saw two peoples bedrooms, with their permission. One was pleasant and had lots of the persons own belongings, while the second was quite bare and the person Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: whose room it is told us that he doesnt want to have more things. Since our last visit he had bought a new DVD player for his room. There are enough bathrooms, shower rooms and toilets for people to use. All areas of the home were clean on the day we visited. People are responsible for keeping their own bedrooms clean, with varying amounts of support from staff. A housekeeper is employed to look after communal areas, but everyone is involved in keeping the home looking good. Care Homes for Adults (18-65 years) Page 20 of 28 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. The staff recruitment procedures are thorough and staff receive good training so that the people living at Rivacre are supported by suitable, well qualified and experienced staff. Evidence: Rivacre House has a small staff team of nine people. Five work full-time and four parttime. Agency workers are used to cover staff absence due to holidays, sickness, training etc and this is a significant number of hours each month. It may be preferable to recruit an additional member of staff who could fill the gaps with greater continuity. Most of the staff have been working at the home for several years, some since it opened in 1992. There is a good mix of age, gender, skills and experience among the staff team and most are qualified to at least NVQ level 3. There are usually two members of staff on duty during the day, plus the manager from Monday to Friday. A senior member of staff sleeps in each night. The staff we spoke with said that there is no need to have waking night staff as all residents would be able to call for assistance should they need it during the night. The home has a recruitment procedure for new staff, and there has been one new member of staff since our last visit. He is the first new staff member for several years. Recruitment is done from head office. The home manager looks at the application Care Homes for Adults (18-65 years) Page 21 of 28 Evidence: forms received, short lists and interviews. The forms are then sent back to head office. They were able to provide us with evidence that a criminal records bureau disclosure and two good references had been received for the new member of staff before he started working at the home. These are to check whether he will be safe to work with vulnerable people. The new member of staff had been working through the homes induction process with the manager, but the form used to record this had not been signed to show what had been completed. Further training, provided at the head office in Warrington, had been booked for this person. Each member of staff has a personal development portfolio and these show that staff members have all attended a very wide range of relevant training over the course of the year. Management staff have completed a year long management training course. Individual training needs are identified at regular supervision meetings with the manager. Staff receive annual updates for medicines, fire safety, moving and handling and health and safety. Senior staff are qualified first aiders. There are regular staff meetings every six to eight weeks, the most recent before our visit being on 23 June 2009. The minutes showed a broad agenda with all staff contributing. All staff have a six-weekly support meeting with their manager and there were records to show the dates when these meetings had taken place. We received seven completed questionnaires from members of staff. They all confirmed that they receive good training and have regular supervision meetings with their manager. Staff comments included: We support residents in their day to day living very well. We encourage residents to be independent as much as possible. Staff take great pride in the responsibility they hold. To keep improving every day and not to rest on our laurels. This is very important to the continued success of the running of Rivacre House. Provides a very comfortable environment with a homely and friendly atmosphere. Committed and consistent staff team. Residents treated with dignity and respect and encouraged to be as independent as possible. Effective systems and procedures in place to enable staff to work efficiently and feel valued by the manager. Staffing levels higher would enable staff to participate in social events and activities Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: with residents outside the home more often. Staff team work very well together and are made to feel valued by the manager. Helps them maintain independence and to be part of the community. Person-centred plans for each individual. Staff training and supervisions. Can talk with manager at any time. We can always improve. Be open to new ideas. The home strives to ensure that people living here remain as independent as possible while living with mental health issues. If the client needs assistance the manager and staff are available 24/7 to assist if need be. Care Homes for Adults (18-65 years) Page 23 of 28 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is very well managed to ensure that the people who live there can be as independent as possible and staff feel supported and valued. Evidence: The home manager has worked at Rivacre since 2003 and was appointed as manager in 2005. He was registered as manager by the CSCI in 2007. He attends a managers meeting every two months and is supported by an area manager. During a visit earlier this year, one of the residential support workers told us: The manager is wonderful, we all work as a team. When we come on duty we split the jobs and the manager is happy to work as part of the team and will do any jobs, he doesnt sit in the office. Information notices about best practice in mental health are displayed in the office and Making Spaces provides a number of information leaflets about mental health. The company has achieved the Investors in People award. A senior manager visits the home monthly and completes a report on how the home is running. Company policies and procedures were all updated in June 2009 to make sure that the guidance for staff they contain is accurate and up to date. Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: One of the deputy managers takes responsibility for carrying out an annual satisfaction surveys with staff, residents, families and professional visitors. There is also an annual audit of all functions of the service. Medicines are checked twice a day and there is also a full monthly audit. Care plans are updated monthly by key workers and checked at random by the manager. Notifications of any serious incidents are sent to the Commission as required. Accident forms are completed well and are all seen by the manager. These all help to make sure that the home is being run safely and well for the people living there. A staff meeting is held every six to eight weeks and resident meetings are also held every six to eight weeks and are well attended. At present there are no regular meetings for relatives as people didnt attend and residents are able to speak for themselves. One of the deputy managers takes lead responsibility for health and safety within the home. We were given details of regular testing and servicing of equipment. The fire alarm, emergency lighting and call system are tested weekly and two fire drills are held each year, the most recent before our visit being in December 2008. Portable electrical appliance testing had just been completed. Water systems are being tested for legionella. These tests all help to make sure that the home is a safe place for people to live and work. Care Homes for Adults (18-65 years) Page 25 of 28 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 28 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 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 20 The cupboard used for storage of controlled drugs should be checked to make sure it meets the requirements of the Misuse of Drugs Act (1971). There should be written guidance for staff about when medicines prescribed as required should be given, to ensure a consistent approach. 2 20 Care Homes for Adults (18-65 years) Page 27 of 28 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. 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