Inspection on 20/04/09 for Shaftesbury Place

This is the latest available inspection report for this service, carried out on 20th April 2009.

CQC found this care home to be providing an Good 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

Shaftesbury Place 12/07/07

Shaftesbury Place 05/06/06

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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: Shaftesbury Place 52 Marsland Road Cheltenham Glos GL51 0JA     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: Lynne Bennett     Date: 2 1 0 4 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 29 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 29 Information about the care home Name of care home: Address: Shaftesbury Place 52 Marsland Road Cheltenham Glos GL51 0JA 01242227818 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) : sarah.martin@sanctuary-housing.co.uk Sanctuary Care Ltd care home 18 Number of places (if applicable): Under 65 Over 65 0 0 learning disability physical disability Additional conditions: 18 18 The maximum number of service users who can be accommodated is 18 The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories Learning disability (Code LD) Physical disability (Code PD) Date of last inspection Brief description of the care home Shaftesbury Place is home for 19 people with a physical disability and mild learning disability. The home is owned by Sanctuary Care who are responsible for the provision of care and the tenancies of people living at the home. Shaftesbury Place is purpose built for people who are wheelchair users and the accommodation has level access throughout. There are four self-contained units each providing single accommodation, bathroom/shower and toilets, as well as a kitchen and dining area. There is a large communal lounge and separate laundry facilities. There are supported living flats on the first floor three of which are registered. Theses flats have a bed-sitting room, bathroom and kitchen. Each person has a tenancy agreement in place and receives a weekly personal food budget. If they have a private telephone or internet access they Care Homes for Adults (18-65 years) Page 4 of 29 Brief description of the care home will pay for this. Base fees are 859 pounds per week. Some people receive funding for holidays from their placing authorities and others may have to pay towards the cost of holidays. People also pay a contribution towards transport costs that is calculated using a fixed mileage rate. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection took place in April 2009 and included two visits to the home by one inspector. We (The Care Quality Commission) were joined by an Expert by Experience. An Expert by Experience is used to describe a person who uses services and has chosen to become more closely involved with us developing their skills, knowledge and expertise. The manager was present throughout the visits to the home. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). Care Homes for Adults (18-65 years) Page 6 of 29 During the vists we spent time talking to people and staff about the service provided. We talked to 3 people using the service, and asked staff about those peoples needs. We also looked at the care plans, medical records and daily notes for these 3 people. This is called case tracking. We also examined a range of other records including staff files, health and safety documents and quality assurance audits. Prior to the visits we received surveys from three people living in the home and health care professionals. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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 8 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 9 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. People have access to the information they need enabling them to make a decision about whether they wish to live at the home. An assessment of the persons wishes and needs are taken into consideration before offering them a place. Evidence: The home has a Statement of Purpose and Service User Guide which were up to date providing people with current information about the home. The manager had a copy of a draft of the Service User Guide which had been developed using photographs, pictures and plain English. This was due to be made available to people in the home. Each person had a copy of their terms and conditions providing information about the service they receive and any additional costs. These had been put in place in February 2009 and some people living in the home had signed their copies. Since the last inspection there had been an increase in the numbers of people being provided a service to include an additional person living in the flats above the home. There had been no new admissions to the home. The AQAA stated that a full Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: assessment of needs would be completed by the home and the necessary information obtained from placing authorities prior to visits to the home and admission. It stated, When we are happy that all needs can be met, the prospective service user will be offered a placement at the home for a trial period of 12 weeks. Care Homes for Adults (18-65 years) Page 11 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. People are being involved in developing their care plans that reflect their aspirations and needs. Risks are being managed safeguarding them from possible harm. Evidence: A new care planning format had been put in place since the last inspection. Representatives from Sanctuary Care homes had met to discuss a new format being introduced at their regular SHIRE meetings and had fed back that they preferred the old care planning process. An agreement was reached to revert back to the old format with some changes making it more person centred in its approach. The files for three people were examined and others sampled. Some people keep copies of their plans and other records in their rooms and people were being encouraged to sign their plans as they were developed with them. Each person had a holistic assessment of their physical, intellectual, social and emotional needs which were summarised in their care profile. From this a summary of their needs were identified along with goals and objectives and a series of care plans. These care plans were clearly written providing Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: guidance for staff on how people wished to be supported in their day to day lives. Plans were clear, succinct and person centred. These were being evaluated each month. There were inconsistencies in the quality of recording in these evaluations with some providing a picture of what people had achieved, what had changed or what was being maintained. Other evaluations noted no change which did not give the reader an overall picture of what was working well or what was not working well. Daily diaries provided information about what people were doing on a daily basis and were again inconsistent in the quality of recording with some records making subjective statements about people. Some staff had received training in record writing and staff were observed supporting each other to write records. The manager was monitoring the quality of record keeping. It was evident that peoples changing needs were being monitored and care plans amended to reflect these along with access to the appropriate support from other health care professionals. Staff spoken with had a good understanding of peoples needs and were observed supporting them in line with their care plans. Where restrictions were in place, such as the use of lap belts with wheelchairs, there were risk assessments and protocols in place for the use of these with the rationale noted. Some people had signed these. Each person had a communication care plan in place indicating the support needed to enable them to express themselves whether verbally or with the use of a communication aid. People using communication aids were observed chatting with staff and other people during the visits. Risk assessments had been developed for hazards identified in care plans providing a summary of how they could be minimised. This enabled people to take risks in a managed way encouraging them to be as independent as possible. A missing persons file was in place providing a pen picture for each person with a current photograph. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to make choices about their life style and supported to develop life skills. People have the opportunity to participate in social, educational, cultural and recreational activities that reflect their personal expectations. Evidence: Each person had an activity schedule in place indicating routine activities such as attending colleges, day centres and doing voluntary work. People said they went bowling, playing bingo and to the pub regularly. During the visits to the home people were going to a social club and one person was supported to attend a monthly Womens Guild meeting. Another person went swimming and others went shopping. Some people said they liked to go to the cinema and to support their local football team. Day trips were being planned. People had taken holidays last year and were planning this years holidays to the Lake District. A number of people were being Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: supported to follow their spiritual beliefs each Sunday, although peoples spirituality had not been identified in their care plans. People were having regular access to family and friends. Some people kept in touch by visits or using their mobile phones or Internet. People were observed having visitors during our inspection or going to visit their family and friends. People were also being supported to keep in touch with friends at social clubs. People were observed doing their laundry, shopping, preparing or cooking meals and helping with the cleaning around the home. Some people have keys to their rooms. All people have lockable facilities in their rooms. Routines around the home were flexible. It was noted that one care plan stated, I will tell staff when I wish to go to bed. Daily records indicated that this was the case and times for going to bed were flexible. People booked times for getting up in advance so that staff provided support with their personal care when they wished. This appeared to work well for people. Consultations were ongoing about the provision of meals. People had individual budgets to plan, shop for and cook their meals. On occasions people were having communal meals in their units and celebrating special occasions or festivals together as a home. They would share the costs of these meals. The manager said that Sanctuary Care were in the process of recalculating the amount each individual was being given towards their provisions budget. The implications of this were a reduction in the amount each person was receiving. There were also discussions taking place about pooling resources to buy provisions for each unit and cooking meals together. People were being involved in the discussions about this and had been asked for feedback. Some people indicated that they were unhappy with these changes and felt that their independence was being compromised. They said that Sanctuary Care had said that if they wished they could retain their individual budgets but at the reduced rate. One person said that they shopped on line for their groceries whilst others were supported to use local supermarkets. Individual meal records were being maintained and staff were encouraging people to have a nutritional and healthy diet. Although at times this was seen to be difficult with people choosing to eat convenience foods or food high in fat or salt content. A cooking club had been set up which people said they were enjoying. Where identified people were being referred to a dietician or Speech and Language Therapist for assessment about their diet or support with eating their meals. Care Homes for Adults (18-65 years) Page 15 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the handling of medication and training of staff. Evidence: The way in which people wished to be supported with their personal care needs were clearly identified in their care plans. Staff spoken with had a good understanding of the needs of the people they support. They were observed treating people respectfully. Comments received in a survey indicated that they had at times been concerned about the tone in which people living in the home had been spoken to by staff. What may be seen as encouragement may also come across as bullying. This had been commented on by people living in the home previously. People said they had key workers with whom they monitored their care plans and spent designated time with. Peoples routines had been identified in their plans and were respected as far as practicable. Incidents and accidents were being recorded. Body maps and other monitoring records were in place. There were some Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: inconsistencies with recording on these records although it appeared staff were monitoring peoples well being from entries in daily records. Pressure sore risks were being assessed and monitored. Health action plans were being put in place for each person. Records of appointments with a range of health care professionals indicated that people were having regular access to their Doctor, Dentist, Optician, Chiropodist, Wheelchair assessment centre and members of the local Community Learning Disability Team. Referrals to Physiotherapists and Occupational Therapists were taking place when necessary. Outcomes of appointments were being recorded. Medical notes were being kept which also appeared to record duplicate information to daily records. The changing health care needs of people were being monitored and people were referred to the appropriate health care professionals for assessment and support. Care plans had been amended to reflect this. Staff were being trained in the safe handling of medication and were being assessed for competency on a regular basis. After a series of medication errors the way in which medication was administered was reviewed and changed. Senior staff described the processes in place which included using the medication trolley and two members of staff administering medication and completing the medication records. We had been informed of the medication errors. At the time of our visits the medication administration records were satisfactory. Medication was administered from blister packs for most people. Liquids and creams had been labelled with the date of opening. Stock records were being maintained. The temperature of the cupboard and fridge were recorded. A new copy of the British National Formula was in place. Protocols for the use of as necessary medication had been authorised by a Doctor. Likewise a homely remedy record indicated that a Doctor had agreed to their use. Care Homes for Adults (18-65 years) Page 17 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that should safeguard people from possible harm or abuse. Evidence: The home had a complaints policy and procedure which was accessible to people living in the home being displayed on a notice board. People had regular house meetings which were used to express concerns. The AQAA stated, We have an open door policy. Complaints are actioned straight away. People said if they had concerns they would talk to staff or management. They also said they would talk to senior management of Sanctuary Care. Surveys indicated that people knew how to make a complaint. The Expert by Experience commented that people were aware of the complaints procedure and confident that any concerns were taken seriously. A complaints log had copies of four complaints received between 2008 and 2009 with a copy of responses and the outcomes of complaints. Staff had completed training in the safeguarding of adults and had access to local policies and procedures. A copy of Sanctuary Cares procedure for reporting abuse was displayed in one of the offices. The manager confirmed that some staff had completed training in the Mental Capacity Act and Deprivation of Liberty safeguards and that further training was planned. Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: Any incidents were being recorded and monitored by Sanctuary Care. Staff confirmed that these were very rare and that no form of physical intervention was used. Robust procedures were observed to be in place to monitor and safeguard peoples personal finances. Each person had a care plan detailing the support needed to manage their finances. Some people had needed support with budgeting and to manage debts. Substantial work had been done over the past year in this area with positive effects. Guidelines were seen to be in place for the use of personal bank cards when support was needed from staff. Finances were checked at each handover. Bank records were reconciled with other records and receipts for purchases kept. Care Homes for Adults (18-65 years) Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Long term plans for refurbishment of the home will improve access for people and provide a home which is more welcoming and brighter. Evidence: At the time of the visits the home was clean and tidy. A domestic was employed to oversee communal areas but otherwise staff and people living in the home share responsibility for keeping the home clean. There were long term plans to refurbish communal areas in the home, to install a lift and make changes to communal areas on the ground floor. The Expert by Experience noted that communal areas and units were very dark and that kitchens were not designed to enable people access to the facilities. The visitors toilet needed some attention and facilities for people with a disability could be upgraded. People were observed using communal areas and enjoying the patio garden to the rear of the home. There were plans to provide raised flower beds to the front of the home and to provide an area for growing vegetables in the back garden. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: Specialist adaptations had been put in place where needed and over the last few years assisted baths and wet rooms had been provided. These were in good condition. Some people had been provided with profiling beds and new equipment. The relevant health care professionals had been involved. The laundry was clean during our visits with good infection control measures in place. Some people do their own washing and a domestic washing machine had been provided for this purpose. Sluicing facilities were in place with facilities for disposal of clinical waste provided. Hazardous products were stored securely and data sheets in place. People were unsure about who had responsibility for replacing pillows and duvets. Some appeared to be very worn. These need to be monitored and replaced when needed. Care Homes for Adults (18-65 years) Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are met by a competent staff team, who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. Recruitment and selection procedures should protect people from possible harm. Evidence: The AQAA stated that over 60 per cent of staff had a NVQ at Level 2 in Health and Social Care or above. The manager was being trained as a trainer of the Learning Disability Qualification which she would then cascade to new staff as part of their induction. New staff confirmed that an induction programme was in place and that they shadowed staff before working shifts unsupervised. They indicated that they had been given sufficient guidance and support during this period of time. The home had no vacancies during our visits but had just recruited a number of new staff. The Expert by Experience commented on the warm and friendly atmosphere between staff and residents. She said that she observed people being treated with respect and noted that staff had time to play a game of tennis with people. Recruitment and selection records were examined for five new staff who commenced work at the home between June 2008 and April 2009. Application forms provided a full Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: employment history and there was evidence that where there were gaps these had been researched with additional information being provided. Each person had two references and a satisfactory Criminal Records Bureau (CRB) check in place prior to appointment. No staff had been appointed before the CRB was received. A risk assessment was available should staff be appointed without this describing what duties they could do. Evidence of referral to Occupational Health was contained on one file. Proof of identity was provided with each file including a current photograph. It is recommended that copies of birth certificates are not kept in line with Data Protection requirements. Proof that these records have been seen can be recorded on staff files. A training matrix was in place which the manager stated was being monitored and amended with new training. This provided evidence that staff were receiving refresher training when needed. Staff confirmed that they had received lots of training recently although increasingly training was provided through open learning packages electronically. Copies of certificates and test booklets were on staff files. There was evidence that some training was being sourced externally. Some staff were completing dementia training. Care Homes for Adults (18-65 years) Page 23 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a well run home. Effective quality assurance systems are in place involving people who live there. Satisfactory health and safety systems are in place providing a safe environment. Evidence: The manager has considerable experience supporting people with a physical disability. She has a NVQ 4 in Health and Social Care and Registered Managers Award. She was completing a Learning Disability Qualification at the time of the inspection so that she could cascade training to other staff in the home. She was also an appointed person in First Aid. She was completing an award in Dementia and would be attending training in the Mental Capacity Act and DOLS. The manager completed an AQAA (Annual Quality Assurance Assessment) providing considerable information about the service and plans for further improvement by the deadline. Her application to become a registered manager was being processed by us and an interview had been arranged. Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: Sanctuary Care had systems in place to monitor the quality of the service provided in the home. The home had completed self assessments throughout the year and had obtained over 90 per cent in the last assessment. An external annual audit was being conducted annually with an action plan produced for the home. Unannounced Regulation 26 visits to the home were taking place and copies of these reports were examined. People living in the home said they were involved in these and were asked to give feedback. Annual surveys were also in place with people living in the home. A representative from the home attended area meetings known as SHIRE (Sanctuary helping involve residents equally) and minutes of these meetings were displayed on a notice board. Systems were in place for the monitoring of health and safety around the home. Records confirmed that regular checks were in place for fire sytems and water outlets. Fridges and freezers had been monitored until earlier this year but new fridges and freezers were provided and thermometers had not been provided with them. Staff confirmed that these were being obtained. During the first visit there was no evidence that the temperatures of hot food was being recorded. It was reported that forms had been put in place on our second visit. A current fire risk assessment was in place and individual fire risk assessments for each person. The AQAA confirmed that servicing of equipment and utilities was in place. Sampling of records for Portable Appliances and Fire equipment confirmed this. Care Homes for Adults (18-65 years) Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 6 Evaluation records should provide a comment on the care plan. Records should use plain English and should be objective. Daily records should use plain English and should be objective. Peoples spirituality or religious beliefs should be identified in their care plans. Ensure consistent approach to completion of monitoring records such as body maps. Monitor and reflect on interactions with people living in the home promoting positive communication at all times. Review content of medical records to avoid duplication of information. Consider upgrading the visitors toilet and replacing specialist adaptations. Review access for people to kitchen units and consider the provision of high low surfaces. Monitor the condition of pillows and duvets and replace where needed. 2 3 4 5 6 7 8 9 6 11 18 18 19 27 29 30 Care Homes for Adults (18-65 years) Page 27 of 29 10 11 12 34 42 42 Photocopies of birth certificates should not be kept in line with Data Protection Recommendations. Thermometers must be purchased for fridges and freezers. Daily records should be kept. Temperatures of hot food should be recorded. Care Homes for Adults (18-65 years) Page 28 of 29 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. 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!