Inspection on 01/06/09 for Windmillbanks

This is the latest available inspection report for this service, carried out on 1st June 2009.

CQC found this care home to be providing an Good 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windmillbanks 30/08/06

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

Key inspection report CARE HOME ADULTS 18-65 Windmill Banks 1 Windmill Banks Higham Ferrers Northants NN10 8JF Lead Inspector Judith Roan Key Unannounced Inspection 1st June 2009 11:00 Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 1 This report is a review of the 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. 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 home adults 18-65 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. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 2 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 Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill Banks Address 1 Windmill Banks Higham Ferrers Northants NN10 8JF 01933 315321 01933 317321 info@windmillbanks.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Claude Fonseka Mrs Viola Fonseka Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The registered provider is registered to provide personal care to male and female service users who fall within the following categories: Learning Disability LD 18-65 years at Windmill Banks care home. The maximum number of people to be accommodated at Windmill Bank is 8. No person over the age of 65 years who falls within categories LD should be admitted to Windmill Banks Care Home. 31st July 2008 Date of last inspection Brief Description of the Service: Windmill Banks is a registered service for 8 people with a Learning Disability. The home is situated in a residential area of the village of Higham Ferrers close to local amenities and on a bus route. Full information on the service is available from the Registered Owner in the Statement of Purpose and the Service Users Guide and various policy documents. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people who use the service and their views of the service provided. This process considers the services capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two people who use the service and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The Inspector also received questionnaires completed by two relatives and staff. The questionnaires provided good feedback of the quality of care and service. The homes registered manager also completed an Annual Quality Assurance Assessment (AQAA) a questionnaire required to be completed by CSCI. The inspection was unannounced and was undertaken during the morning and early afternoon and lasted 5 Hours. The fees at the home start from £895 a week and depend on the level of service required. This is assessed and agreed during the preadmission process. What the service does well: What has improved since the last inspection? Support plans are in place and provide clear details on need. Medication administration is accurately recorded and monitored. Policies and Procedures for dealing with violence and aggression are now in place. All bedrooms have the required facilities. Repairs have been carried out. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 6 Plans have been made to increase the size of the communal area within the home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 People using the service experience good quality outcomes in this area. A detailed assessment is carried out to ensure that people considering a move into the home can be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The service user guide and state of purpose contain all the information required by the regulations under the Care Standards Act 2000. The service users guide needs is not available in an accessible format that is understandable by people that may use the service. People considering a move into the home will have their needs fully assessed using the organisations assessment tool. Visits will be made to individuals to assess their needs together with visits to the service. Undertaking the admissions process ensures that the service can meet the needs of people prior to moving in. In case tracking people who use the service we found that assessments had been made to clearly identify the needs of individuals. The files also contained care plans completed by care managers or community nurses of their funding Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 9 authorities. Each person had a detailed contract and terms and conditions on their file. At present the service is providing support to only 2 people after several people have moved out into supported living services. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People using the service experience good quality outcomes in this area. Support plans provide good details to ensure that people using the service have their needs met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The care files of two people using the service were reviewed and reflected current needs. Support plans have been updated and are reviewed as required. The support plans have improved significantly since the last inspection. The outcomes for people who use the service are in the main positive. In discussion with people who use the service they confirmed that their needs are met and that support staff always involve them in every aspect of their care. The support available for individuals enables them to participate in everyday activities if they choose to do so. Personal learning could be improved by a more consistent approach by support workers. This would promote opportunities for individuals to be fully involved and or observe a broad spectrum of daily living activities. Risks within activities are considered on an individual basis and plans made to Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 11 minimise these for each person. Everyone is encouraged to be as independent as possible with appropriate support. Support plans in place are updated to meet peoples changing needs. Support workers confirmed that each person is involved in the development of their plans within their ability. They also demonstrated during the inspection the importance of the person using the service and their family/advocate being involved. A survey received from a relative confirmed that they were very satisfied with the service provided for their relative. The AQAA states that ‘The people who use our service are given as much choice on as many aspects of their lives as possible. These choices are supported by the staff that ensure that the service users are able to benefit by them in the best possible way.’ In observation of practice support staff demonstrated good practice in relation to enabling people to make choices throughout the day. The support plans are underpinned by risk assessments that enabled the staff to promote independence for individuals within their disability and to minimise the risks. One-person however was able to be left for short periods of time on the basis that they knew how to summon support from staff who work in the adjoining home. A risk assessment needs to be place for this area of activity to ensure that all potential risks have been identified and the person is protected. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16,17 People using the service experience adequate quality outcomes in this area. Activities are not consistently organised and are dependent on staff availability. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The support plans identified each persons choices of activities that they would like to do during the day. Individuals however do not have regular planned activities. Activities tend to be spontaneous and are linked to the number of staff on duty. On the day of the inspection one person was supporting two people during the morning. This staff member also had domestic tasks to complete like laundry and meals. It was therefore not possible to undertake all of the activities that people would wish to do. In discussion with staff members there were times when two people were on the rota to provide an opportunity for people to access the community. A vehicle is available for use. There are three members of the staff team who are Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 13 able to drive the bus. Spontaneous activities are therefore curtailed if any of these staff are not on duty. Current practice is top book the mini driver in advance. A survey was received from one relative who expressed concern that the normal support to enable their relative to visit them was not available on a regular basis. They therefore feel that there has been a reduction in the service over the past few months. Outcomes for people in this area are therefore not consistently met and do not meet national minimum standards at present. Information contained within the AQAA that ‘The people who use our service are given as much choice on as many aspects of their lives as possible. These choices are supported by the staff that ensure that the service users are able to benefit by them in the best possible way.’ Does not reflect what is happening in practice. Meals are prepared by support staff and are freshly cooked. In discussion with people using the service they said that they had a choice of meals and were very happy with the menu at present. The meals can be eaten in the lounge/dining room or in the rooms of people using the service. Visitors are welcome at the home with no restrictions on visiting times. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People using the service experience good quality outcomes in this area. People using the service will have their health care needs met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Support plans provide information about the healthcare needs of individuals living out the home. There is evidence within daily notes that people are supported to attend healthcare appointments as required. The personal choices of people using the service are respected in relation to how people prefer to be supported with their personal care. The service provides gender appropriate support to meet the needs identified within support plans. All medication is administered at present by support workers and medication profiles are available to provide information about the person and why they need a specific drug. In reviewing the records held at the home improvements had been made in recording and no errors were found at this visit. The provider needs to review the storage facilities at the home so that they comply with the new regulations in relation to care homes and controlled drugs that came into force in 2007. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 15 The AQAA confirms action taken to improve this outcome area since the last inspection. ‘Staff members provide sensitive and flexible support when the service users need it. Service users are supported to choose how they dress, their personal appearance and their hair style. We have begun an in house training programme on the principles of care, dignity and respect. We now carry out a strict regime of monitoring and checks on medication administration to ensure no mistakes are made. We have trained new staff and retrained existing staff to ensure that they are competent to administer the medicines. We have been able to reduce the incidence of medication administration errors to zero in the past six months.’ Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People using the service experience good quality outcomes in this area. People using the service are listened to and feel safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People spoken to said that if they were worried about anything they would speak to staff or the Manager and they thought it would be followed up. One person has limited communication and it was not possible to know if they knew how to complain or raise a concern. In discussion with a staff member they said that they would know if the person was unhappy by the non verbal communication or change in their behaviour. Staff also demonstrated that they had a good understanding of whistle blowing procedures and how to raise concerns about abuse. The home has policies and procedures, including the No Secrets and Protection of Vulnerable Adults documents. Training is provided on safeguarding as part of the induction process. Staff recruitment checks include a Protection of Vulnerable Adults (POVA) first check and a Criminal records Bureau disclosure (CRB) for everyone that works at the home. Two references are also completed. Accident and Incident Records were checked and it was found that staff had reacted appropriately to all situations presented. The incidents are not however routinely notified to CQC as required by regulation 37 of the Care Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 17 Standards Act 2000. The AQAA received confirms that ‘The people that use our service have the complaints procedure explained to them by staff members using the communication medium best suited to that individual. We have monthly meetings for our service users where they are given a chance to raise any concerns or complaints with support from staff and key workers acting as advocates. The Complaints Procedure seen by the inspector reflects the National Minimum Standard in that it has set stages linked to timescales. It does need to be produced in an accessible format for people using the service. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 People using the service experience adequate quality outcomes in this area. Some improvements have been made to the environment but additional communal areas have yet to be completed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection plans have been passed by the council for an additional room to be built to the rear of the property which will provide additional communal area and laundry provision. This is in process and will improve the space available for people using the service and provide a designated area for meals. Repairs have been undertaken to the room seen at the last inspection where damage had occurred. Bedrooms contained required furniture and provided ensuite facilities for individuals living at the home. Support workers undertake cleaning as part of their role. This does detract from the support that they are able to provide for people using the service. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 19 Some carpets were in need of cleaning where food had been dropped or spilt. There was an unpleasant odour within the home. The provider may have to review the floor coverings to maintain them so that they are both clean and safe. The senior member of staff on duty stated that they would address the issue the next day. The AQAA states that ‘We have 8 spacious single bedrooms with ensuite facilities, all of which are over 12 square metres, excluding en-suite and a choice of living areas. Key workers offer support to allow the residents to personalise their own rooms as they wish. Residents are involved with choosing how communal areas look and how they are arranged. Every service user has their own room. We have a lift to allow residents with mobility difficulties to access 1st floor of the home. All areas of the premises are accessible to wheelchair users.’ Infection control is maintained by use of disposable hand towels and the provision of alcohol gel dispensers are situated by exits and in the kitchen. The specialist equipment used within the home is serviced and maintained in good working order. The development of a larger laundry is hoped to provide safe access for people using the service so that they can be supported to undertake this task. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35 People using the service experience adequate quality outcomes in this area. Staffing numbers do not always enable people using the service to have their choices met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There was one member of staff on duty at the home during the inspection. The manager also visited and was providing support in the absence of the manager who had recently left. This level of staffing did not provide sufficient levels of support for the two people living at the home. Support workers are also expected to carry out domestic tasks and meal preparation. In discussion with the staff member on duty they confirmed that on some days the support worker on the late shift came in early to help and assist people with activities in the community. The provider needs to review the rota to ensure that activities of choice are undertaken with people using the service. It is unacceptable for people using the service not to have sufficient staff on duty to meet their identified and agreed needs. Staff files contained the required employment checks that included an application form, two references, and a criminal record bureau disclosure Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 21 check. The files also contained copies of certificates confirming that staff had completed mandatory training. The AQQA confirms that 75 of support workers employed have attained the National vocational qualification (NVQ) in care at level two or above. Staff training is available and accessible for staff with many training programmes being online. The two members of staff spoken with at the inspection by the held NVQ at level three. The provider confirmed that developments for the future include the learning disability qualification as part of an induction programme for new staff. Staff supervision is undertaken and records are maintained in personal files. Supervisions are not on a regular basis and it is the intention of the provider to improve this area so that they meet national minimum standards. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 People using the service experience good quality outcomes in this area. The service is in the main run in the best interests of the people using the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection the acting manager has resigned and left. One of the owners is presently undertaking the manager’s role and confirmed at the inspection that they would continue to do this until the service required a fulltime manager. They have appointed a senior support worker to provide experienced cover as they were not in the home all of the time. The staff member has experience of working in a similar position at another home for people with a learning disability. The owner and senior support worker provide on call support to staff who are working on their own. The quality assurance systems in place records the views of people using the Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 23 service through the use of questionnaires and comments made in-house meetings held at the home. The AQAA confirms that ‘We send customer satisfaction surveys to the family and friends of our service users. They are invited to fill in a customer satisfaction questionnaire. The findings from the customer questionnaires are used to address any issues and are available to everyone.’ This information is not analysed and collated to provide a quality assurance report. It is therefore difficult to confirm that issues raised by people using the service or their relatives have been addressed. Financial records were reviewed during the inspection and found to be in order and in an acceptable format. People using the service are therefore protected. In reviewing the health and safety records we found omissions within then fire records. In the absence of the previous manager it was difficult for staff to know where these were stored. At the previous inspection records were available and maintained. We have no reason to believe that health and safety checks had not been undertaken. During the inspection the manager from the adjoining home confirmed that professional checks had been undertaken at their home and they were sure that these checks were also completed at Windmill banks. It is advisable that the provider ensures that records required for health and safety checks under the regulations set by the Care Standards act 2000 are available for inspection at any time. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 2 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 x 12 2 13 3 14 2 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 3 X 2 X Version 5.2 Page 25 Windmill Banks DS0000065013.V375642.R02.S.doc Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA12 Regulation 16 Requirement People using the service must be consistently engaged and supported to undertake agreed activities both in and outside the home. To ensure that people using the service have a positive lifestyle. The provider must review how controlled drugs can be safely stored to ensure that they meet the new regulations that came into force in 2007. The homes shared environment must be fit for purpose and enable people using the service to have access to a range of comfortable, safe and fully accessible shared space for activities. A previous requirement with a timescale of 30/11/08 has been met in part. The carpets at the home must be kept clean on a regular basis to ensure that offensive odours are removed and provide a pleasant environment for people using the service. The provider must rota sufficient numbers of staff on duty to ensure that the identified needs DS0000065013.V375642.R02.S.doc Timescale for action 30/09/09 2. YA20 13 31/10/09 3. YA28 13 16 23 30/09/09 4. YA30 16 31/07/09 5. YA31 18 31/07/09 Windmill Banks Version 5.2 Page 26 6 YA37 10 7. YA41 37 of people using the service are fully met. The providers need to confirm to 31/08/09 CQC the management arrangements at the home to ensure that the service is being managed in the best interests of people using the service. All incidents that affect the well 31/07/09 being of people using the service must be reported to CQC. This is to comply with regulation 37 of the Care Standards Act 2000 and to ensure that people using he service are protected. A previous requirement with a timescale of 30/09/08 has been met in part. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA22 YA39 Good Practice Recommendations An easy read complaints procure would benefit people using the service. It is recommended that the finding of the quality assurance process are analysed and produced in a format that identifies how views are addressed and the service has been developed. Windmill Banks DS0000065013.V375642.R02.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE 1 4PA National Enquiry Line: 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). 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