Inspection on 21/01/10 for Riverswey

This is the latest available inspection report for this service, carried out on 21st January 2010.

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

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

Other inspections for this house

Riverswey 07/12/05

Riverswey 21/06/05

Riverswey 24/01/05

Riverswey 03/08/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Riverswey Newark Lane Ripley Surrey GU23 6DL     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: Kenneth Dunn     Date: 2 1 0 1 2 0 1 0 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: Riverswey Newark Lane Ripley Surrey GU23 6DL 01483224099 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: manager.riverswey@careuk.com Care Solutions Limited care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 3. The registered person may provide the following category/ies of service only: Care home only - (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 (LD). Date of last inspection Brief description of the care home Riverswey is a home accommodating up to three younger adults who have a learning disability. It is situated in a semi-rural position on the outskirts of Ripley village, a few miles from Guildford and Woking town centres. Care UK, operates the service and Hyde Housing Association own and maintain the building. The home is a single storey building set in level gardens with fields to the rear. The accommodation consists of two single bedrooms, a communal lounge, a spacious kitchen/dining room and a bathroom. Incorporated within the house is a single, selfCare Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 3 Brief description of the care home contained flat. This enables a service user to have supported independence. An office, which is also used as a sleepover room for staff and a small laundry room, are provided. The home has a car to transport service users and staff as there is no public transport immediately accessible. The fees at this service range from £ 1726.72 to £ 1892.22 per week. 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: 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: This site visit was part of a key inspection process, it was unannounced. We arrived at 9.30 am and left at 13.30 pm Information was provided to us by the service prior to this visit in the Annual Quality Assurance Assessment. (AQAA). This is a self-assessment that focuses on how well outcomes are being met for people using the service. We received the AQAA by the expected date, which provided us with all the information we asked for. Reference is made to this assessment throughout this report. Other methods used to inform our judgements made in this report include discussions with members of staff and community health based professionals. We looked at training records, care plans, risk assessments, menus, quality assurance systems, medication administration policies, health and safety records and policies and Care Homes for Adults (18-65 years) Page 6 of 29 procedures were sampled. We also reviewed other information that we have received since our previous including notifications that the service is required to inform us about. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: The registered provider must ensure that the home is maintained appropriately in Care Homes for Adults (18-65 years) Page 8 of 29 order to ensure that the persistent issues with the roof is rectified once and for all. This will reduce the damp areas on the ceilings and the cracking throughout the property. The registered provider must ensure that there is a full employment history for the staff group, at the time of the site visit the application form only requires a time period of 7 year of history. 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 9 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 10 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. The needs of potential resident are fully assessed prior to their admission to the home. Prospective residents are provided with sufficient information about the home, to enable them to make the decision about the appropriateness of the home in meeting their needs. Evidence: The home has not admitted any new residents since the previous site visit by the Commission 16/01/2007. The manager provide detailed information about the assessment process in the completed AQAA. During the site visit a senior member of staff explained that the assessment process is designed to ensure that the home could meet the needs of future prospective resident. A member of staff stated that the assessment process requires all prospective residents to visit the home on a number of occasions, usually of increasing length, they would be invited to stay for a meal and possibly overnight, if it appeared that the home was suitable. It was stated, that it is essential that the assessment highlights the compatibility of the prospective resident in relation to the existing residents and to Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: minimise any effects a new member of the household may have on them. The service has developed a statement of purpose and a service users guide that contains relevant information about the home, the services it provides and the staff. A review of these documents demonstrated that they would aid and assist potential residents in making their choice about moving into the home. During the site visit it was discussed that with the member of staff in change during the visit that there is a need to review all contact details of external agencies involved in the care of the residents to ensure they are current. The staff member stated that a audit of the documents would be undertaken and additional information would be added to expand the contact details to allow residents and their families or representatives to have ease of access if they require. Care Homes for Adults (18-65 years) Page 12 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. Care plans are detailed and informative and provide excellent information to staff to offer appropriate support to individual residents. A series of robust risk assessment have been completed. The residents supported and en powered to make independent decisions. Evidence: The home has developed a series of comprehensive care plans for each resident. The care plans clearly highlight the support needs of the individual residents and the services and facilities essential to meet their needs. The completed AQAA states that We have comprehensive person cantered care plans which have been developed with the involvement of the individual service users. These enable staff to meet the identifies needs of each service user the plans are regularly monitored, evaluated and updated with service users involvement and that. Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: During the site visit the member of staff in charge of the home confirmed that all three residents had received an annual multidisciplinary review, during the previous 12 months. This was confirmed by the review of the residents files undertaken during the site visit. The sample of all care plans demonstrated that they were in good order, contained the required information, regularly reviewed and where appropriate resident have been encouraged to sign that they have participated in the review process. The AQAA provided evidence that the home has developed a series of comprehensive risk assessments to instruct staff how to minimise potential risk without restricting service users ability in daily activities. The risk assessment sampled, involved individuals mobility, personal care and bathing, fire, choking and vulnerability to abuse. These were very detailed and included ways to prevent risks and how to manage them to minimise the risks to residents, whilst enabling them to be independent. The residents are again encouraged to sign the assessment to signify they that they have been involved in the process and have had the assessment explained to them. The AQAA sates that staff have good knowledge and skills in supporting and enabling the service users make their choices. e.g. shopping, preparing meals, decorating their rooms, choice of personal electrical items, Service users are encouraged and supported to participate in the running of their home We can offer high support for service users enabling them to do what they want as individuals. They member of staff assisting during the site visit stated that the residents take an active part in where they want to go and what they want to do and the staff group provide support in order to achieve their goals. During the visit observations of the staff interacting with the residents demonstrated that there is a clear understanding by staff of the levels of support each individual required and the support they must offer to enable the residents make independent choices. Care Homes for Adults (18-65 years) Page 14 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are supported appropriately to take part in a range of activities and to participate in their community. Residents are encouraged and supported to plan, shop and prepare a well balanced diet. Evidence: The lifestyle expectations of the residents of Riverswey are excellent. The staff working in conjunction with individuals living at the home have developed a series of highly individualised activities, that are age, peer and culturally appropriate for the residents. The AQAA states we support service users to pursue an active fulfilling life in areas Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: that they wish to explore. They have access to facilities within the local community and any new wants are looked at to see if they can be achieved. A member of staff stated that the residents have individual social activities plans, which are displayed in the home. Their social activities are reviewed as part of their key worker and planning meetings. The staff support the residents to take part in a variety of activities within the local community such as pottery, bowling, cinema, shopping, craft classes and cooking. The residents attend a variety of social clubs within the local community and have developed relationships with many of the people there and have invited them to parties at the home. This was confirmed during the site visit by the manager and a review of the residents individual plans. During the site visit the residents were observed to be coming and going to their planned or spontaneous activities going to their day placements or having an at home day with staff. The commission was provided with details of the planned holidays the residents participated and in their plans for forthcoming holidays. One resident stated that she was going off to Blackpool with staff as her annual trip. During the site visit large photographic displays of the holidays were framed and on display around the house. A random sample of residents files provided evidence that individuals living at this service are provided with the correct levels of support to maintain contact with friends and families. The AQAA stated that we support them to maintain contact with friends and family where possible as well as develop new relationships outside the home. The staff on duty during the site visit stated that the residents are encouraged to maintain contact with their families where possible, we invite families to meetings and reviews and to any parties we have at the house. The residents have a very flexible system in place for meals, they are supported by staff in the kitchen and to ensure that the meals offer a healthy balance. At the time of the site visit two of the residents were being supported on reduction diets in line with directions from medical professional. The residents are supported to purchase their own meals in line with guidance to reduce their weight. On the day of the site visit one resident had started to prepare the ingredients to make a lasagne with staff for his lunch. A member of staff stated that the residents are very keen on helping prepare their own meals and are very knowledgeable about what food they enjoy and what is suitable for them to eat. Care Homes for Adults (18-65 years) Page 16 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has consistent records and robust documentation to evidence that the residents health care, wellbeing and welfare are supported. The homes medication procedures ensure the safety of the people living in the home. Evidence: The care plans demonstrated that the personal support needs of the residents were well documented. Within the residents individual files there was consistent evidence to demonstrate that care plans have been developed and agreed with the resident, families and relevant health care professionals. The AQAA stated that Each service user has a key worker who is responsible in evaluating the service offered to the user and monitoring progress. Key workers are allocated following discussion with service users A sample of care plans evidenced that individual residents are engaged in the planning process. The files demonstrated that where the residents can sign that they have been involved in planning and have been fully engaged in the review process for subsequent plans they have been encouraged to do so. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: The random review of individual care plan provide evidence that all residents are registered with a local general practitioners(GP). It was documented that the residents have access to dentists, chiropodists, opticians and psychiatrist support if required. All medication is stored in a locked in one central medications cupboard and there is documentation to indicate that the medication is reviewed and audited regularly. The manager stated in the AQAA that At present no service users are able to self medicate so all staff are responsible for administrating medication. Competence is assessed and training given before this is undertaken by any staff member. It was discussed with the member of staff in charge of the home during the site visit that there is a need for the home to undertake a full medication risk assessment to highlight if in future the residents could undertake self medication with staff support and assistance. During the site visit a review of the Medication Administration Records (MAR) was undertaken no gaps or errors were highlighted. It was however noted that where corrections had been made to dosages, instructions or new medications added to the MAR sheets there was no clear guidance or explanation as to why these change had been made. This was discussed with the staff who stated that a review of the MAR sheets would be undertaken and explanations and signatures would be included on the sheets in order to clarify the alterations. Care Homes for Adults (18-65 years) Page 18 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 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 use this service benefit from a robust set of policies and procedures designed to protect and safeguard them from abuse. Evidence: A review of the complaints records maintained by the home indicated that there have been no complaints made to the manager and staff since the last twelve months In the AQAA the service stated that Complaints procedure is available in both written and pictorial format. An open culture exists whereby staff feel comfortable to raise concerns they may have. This was confirmed during the site visit the complaint procedure was clearly displayed it was robust and has been produced in a appropriate format to enable the residents to fully access the process. Two resident stated that they understood what to do in the event that they wanted to complain about someone or the home, bot individuals knew where to find the complaints policy and what to do if they felt they needed to. The staff on duty stated that the policy is reviewed on a regular bases and updated when required. It was noted during the site visit that the contact details of external agencies were not clear and could be difficult to access by the residents or their families if they wanted to take a complaint outside of the home. This was discussed with the staff on duty who Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: stated that a review of the contact details would be undertaken and all relevant contact details would be made available to the residents in an appropriate format. There is a clearly written safeguarding adults procedure and a copy of the local authority safeguarding adults from abuse policy was available. The AQAA provide evidence that Protection of vulnerable adults policy in place, Staff trained in POVA and have CRB checks, Risk assessments in place, which identifies service users risk to abuse and that there are Rigorous recruitment procedure in place which checks all applicants against the POVA register. Evidence of staff training was available and reviewed during the site visit. Care Homes for Adults (18-65 years) Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The layout of the home should enable the people who use the service to live in a safe environment. The home is clean and hygienic. Evidence: The home is a detached building the rooms are spacious, bright and fully accessible to the residents. The AQAA states that the The home is divided with two single bedrooms in the main part with lounge kitchen and bathroom and a one bedroom self contained flat which are decorated according to the choices of the service users. The flat has its own bathroom where in the main house only two have to share the bathroom but they have basins in their bedrooms. A partial tour of the building was undertaken as part of the site visit, this included all communal areas and one bedroom and the private residents flat. The manager stated in the AQAA that All furniture and decoration within the home is arranged through consultation with the service users and they are involved in all purchases and that Service users are encouraged to personalise their own room and are assisted to do this. Staff are expected to respect individual space and knock before entering any rooms. The furnature in the home is domestic and suits the needs of the residents. During the tour of the home personalisation of the bedroom seen and the Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: flat was very indavidual to the residet living in that area. The home is relatively well maintained. The home completed a series of mannitance programmes in line with requirments made during the the previous visit by the commission 17/01/2007. There is evidence of the work orders for the maintanince work to undertaken by the landlords, the orders were actioned and completed within a set time frame. It was however noted that the repairs to the roof and celings have not lasted and again cracks have appaered and areas of damp are spreading across the celings of the home. This was discussed with the staff member in charge of the home during the site visit who made assurances that a request for the repairs would be made as a matter of urgency. The home has a good infection control policy. The staff group have all had regular training to ensure that any health and safety issue can be identified and successfully brought to the attention of the correct maintenance provider. During the inspection the home was clean and free from mal odours. Care Homes for Adults (18-65 years) Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff group appeared skilled and in sufficient numbers to meet the needs of the people who live at the home. The systems for recruitment and training are designed to be robust and should protect the people who use the service Evidence: A review of staff duty rotas during the site visit indicated that appropriate staffing levels are maintained in the service at all times. The AQAA stated that Service users are supported well by a stable staff team who have all but one have been hear at least 7 years. This was confirmed on the dat of the site visit by staff on duty and a random review of staff files. The member of of staff in charge of the home during the site visit stated that 100 of the current staff members have completed National Vocational Qualifications (level 2) or above. This was supported in the completed AQAA and the random review of staff during the visit. The inspector was informed that each member of staff has their own training record and a review of these records demonstrated and supported this all have received Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: mandatory training in safeguarding adults, fire, food handling, food hygiene manual handling, health and safety, first aid and managing medication. During a discussion with a member of staff they confirmed that they attended all mandatory training and that the home was dedicated to ensuring all staff were appropriately trained. The home has good recruitment policies and procedures, based on equal opportunities legislation. It was noted however that the application form used by Care UK for recruitment to Riverswey only require potential staff members to supply 7 years employment history and not a full employment history required by the national minimum standards. This was discussed with the staff on duty during the site visit and a request will be made to ensure that all staff have a full and detailed employment history on file as a matter of urgency. It was noted that during the random for review of staff files that the references for some members of staff were not from previous employers and in one case there was only two verbal references on file and again they were not from the most recent employer of the person involved. This was discussed during the site visit and a requirement was made please refer to statutory requirements section of this report. Care Homes for Adults (18-65 years) Page 24 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. The people who use the service benefit from a well run home. The service seeks feed back and has developed a robust quality assurance processes. The health, safety and welfare of residents are promoted and protected Evidence: Reverswey has a very stable management structure the manager has considerable experience working and managing care home for people with learning disabilities. The AQAA states that The manager has completed her NVQ 4 and RMA and has been running the home for the last 8 years. The staff members on duty during the site visit stated that the home is well organised and managed and there is a hand on approach from the manager which ensures she is open and approachable to service users and staff The home holds regular residents and staff meetings which was confirmed by staff spoken to and from records sampled during the site visit. During the sample of Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: records and discussions with staff It was apparent that not all the house meetings are recorded and minuted. The manager stated in the AQAA that in order to improve the service the residents would continue to participate in monthly meetings to discuss ways of improving the company and are being encouraged to become involved in staff interviews and asked for their opinion on new paper work. At the time of the site visit two residents are engaged in a Service Users Involvement Group, which is designed to assist and develop relations between the providers of the service and those people who use the services. A member of staff stated that the home has not undertaken a formal resident Quality Assurance (QA)in the last 12 months as it gains good feed back from the regaler house meetings to provide information regarding the quality of the services the residents receive. The need for a formal annual QA to be undertaken was discussed with staff during the visit and an undertaken was made that the home will action a formal written quality feedback form and distribute it to the residents. The provider carries out a series of monthly regulation 26 monitoring visits to ensure that the service is operating at an appropriate level. As part of the inspection process the regulation 26 log and files were reviewed and found to be in good order. The home has clear well maintained records which are easily accessed by the staff team ensuring that they are kept up to date and precise. The commission received pre- inspection information in the form of a Annual Quality Assurance Assessment AQAA, which indicates that the Care UK provide a range of policies, and procedures to the home. The policies and procedures are regularly reviewed and updated, the manger subsequently brings the information to staff attention during staff meetings. The staff member in charge during the site visit stated that the service has clear risk assessments for individual service users and general risks around the home. The staff are required to read these and be familiar with them during their daily working. There was sufficient evidence in staff files to demonstrated that they undertake training specific to health and safety such as moving and handling, health and safety, food hygiene and fire awareness. Substances hazardous to health (COSHH) were stored securely and appropriately. Health and safety checks are completed and recorded regularly, Gas Certificate , Electrical Certificate, Controlled Waste Contract and Insurance Certificate. . Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 24 23 The registered person must 13/04/2007 ensure that (a) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally and (b) equipment provided at the care home must be maintained in good working order. Care Homes for Adults (18-65 years) Page 27 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 33 19 The registered provider 28/01/2011 must ensure that all relevant information regarding staff must be retained on file. The residents must be protected by the recruitment practises of the home. 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!