Inspection on 30/09/09 for Aeolian House

This inspection was carried out on 30th September 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aeolian House 01/11/07

Aeolian House 11/12/06

Aeolian House 05/01/06

Aeolian House 25/08/05

Aeolian House 07/10/04

Aeolian House 21/04/04

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 24/11/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Aeolian House Horsham Road Cranleigh Surrey GU6 8DZ     The quality rating for this care home is:   one star adequate 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: Lisa Johnson     Date: 3 0 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 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 30 Information about the care home Name of care home: Address: Aeolian House Horsham Road Cranleigh Surrey GU6 8DZ 01483276561 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.mencap.org.uk Royal Mencap Society Name of registered manager (if applicable) Type of registration: Number of places registered: care home 8 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 8. 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 Aeolian House is a care home for adults with a learning disability. The home is a large Edwardian detached house on the outskirts of the village of Cranleigh. All bedrooms are for single occupancy, situated over two floors. There is a large lounge/dining room and kitchen. One sitting room can be used as a quiet room. There are two bathrooms and a downstairs shower room. Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 8 Brief description of the care home The home is situated in its own grounds, laid mainly to lawn. There is adequate parking to the front of the premises. A bus stop is a few minutes walk away. It is some considerable walking distance into the village of Cranleigh. The fees range from £456.67per week to £529.91per week. Care Homes for Adults (18-65 years) Page 5 of 30 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: one star adequate 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. The visit was unannounced. The last key inspection was carried out 27th November 2007. 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 was clear and gave us all the information we asked for. Reference is made to this assessment throughout this report. We received five feedback surveys from people living in the service to gain their views. We also received a surveys from two health and social care professionals and two members of staff. During this visit we met with three people that live in the service and discussion took place with four members of staff. Care Homes for Adults (18-65 years) Page 6 of 30 During this visit we sampled staff recruitment, and training records, care plans, risk assessments, menus, complaint, accident/ incident records, quality assurance systems, medication administration policies, health and safety records and policies and procedures We also reviewed other information that we have received since our previous including notifications. Care Homes for Adults (18-65 years) Page 7 of 30 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. Care Homes for Adults (18-65 years) Page 8 of 30 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 30 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 30 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 are provided with accessible information that they need to know about the home and their needs are assessed prior to admission. Evidence: During this visit we looked at the information provided to people who use the service to see whether it is able to supply everything that people or their representatives need to know. The service provides a statement of purpose and service guide, which is available in alternative formats, which has been reviewed and formulated with pictures to ensure that is it accessible to people. Two people told us during this visit that this information has been provided to them, which was also confirmed by four people surveyed. Since the last key inspection there have been no admissions in the home. The service has a clear admission procedure. Other information is also obtained from care management, previous placement and any relevant health care professionals, which was confirmed by peoples files that were sampled during this visit. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a plan of care that the person has been involved in making. Peoples needs and goals are met and they are able make decisions about their life. People are able to take risks as part of an independent lifestyle Evidence: Each person has a person centred support plan in place, which contained information about their health, personal, emotional, communication, social, life skills relationships, finances, cultural and religious needs. During this visit we sampled three peoples person centred plans, which were made accessible to people with pictures. The overall care plan is reviewed every six months and an annual review takes place. Care plans are also reviewed monthly with the person and their key worker,where people are provided with the opportunity to discuss their goals, changes or any new any activities that they would like to do. People had signed their monthly support meetings confirming their agreement. The service has also developed separate person centred care plans with people, which they Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: keep in their bedroom, which contained photographs. The manager was advised to ensure that this care plan is also kept up to date in line with the copy maintained in the office as the information and dates recorded didnt all correlate. Staff receive training in person centred approaches and diversity awareness is linked into this. Five people surveyed said that they are able to make decisions. The service holds regular house meetings and a person told us, We have lots of meetings and there is an agenda and we talk about lots of things. The service has adapted a range of information in accessible formats to assist peoples understanding including, a pictorial staff rota, which was seen on display to help people to identify who is on duty. Over the last year people have been provided with the opportunity to say what qualities that they would like new staff to have, which is recorded in the homes meeting minutes. People maintain their finances in their bedrooms in a lockable faciliy to maintain their independence and any support they require is recorded in their care plan. A health and social care professional surveyed said, The service encourages residents to lead as an independentlifestyle as possible with care and consideration to their individual needs. The service has implemented a range of risk assessments, which were regularly reviewed. A new risk assessment called managing risks with individuals has been implemented, which is more enabling tool for people to take part in activities. Risk assessments sampled included, road safety, use of the kitchen, finances, travelling and administration of insulin. These had been reviewed and were up to date. Care Homes for Adults (18-65 years) Page 13 of 30 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. Peoples preferences, social, cultural, diverse ,religious and recreational interests and needs are met. People maintain contact with their family , friends , representatives and the local community. People are supported to exercise choice over their lives and are provided with varied and well balanced meals. Evidence: Each person has an individualised, weekly activity schedule, which is outlined in their care plan. At the time of this visit a number of people were attending day services or employment. A person spoken with told us that they work in a supermarket .Another person told us that they do voluntary work in a shop. Another person living in the service also works at a supermarket and two people help out at a day centre for older people near by. People access and use community facilities, some independently, including, going to the shops and banks, visiting cafes Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: and pubs, going swimming and using local transport. A person told us that they visit a social club in Guildford. Three people attend local church groups and attend local activities such as fetes and Fayres. Some people told us that they had been on holiday to Spain this year. Peoples hobbies were also documented in their care plans and a person told us they like to knit and another person likes to grow items in the garden, which was confirmed by a member of staff who showed us the flower display and tomatoes that they had grown. Five people surveyed said that they are able to do what they want to do during the day, evening and at weekends. A person surveyed said, We have group activities, parties and I go on shopping trips. People maintain links with their family and friends. The organisation (Mencap) has a families charter, which encourages and guides staff in supporting them to maintain and strengthen family connections that are important to them. Some people visit their families at weekends. A person told us about their relative whom they see reguarly. Another person visits their relative independently. Care plans sampled also included information about peoples other means of maintaining contact such as telephoning and writing cards. A number of people living in the service have their own mobile telephones. One person told us that they keep in touch with old friends that they see at a social club that they attend. People are supported to assist with the running of the home and have created a list of chores and they have planned who will do this each day. People also take turns each day to assist with cooking and a photograph of the person was seen on display next to the menu. A person spoken with told us that they do their washing and that they like to cook and another person said, I do hoovering and washing up.The home has two cats called Pinky and shandy, which people assist in caring for. People meet weekly to discuss and choose the menu for the week. The menu was observed to be varied and well balanced. Three people spoken to during this visit said that they like their meals. Healthy menu planning is encouraged and a healthy eating plan has been put in place for one person due to a health matter. Care Homes for Adults (18-65 years) Page 15 of 30 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. Peoples health and personal care needs are met and peoples preferences for support are respected. The home supports people with their medication in a safe way. Evidence: Peoples health, emotional and personal care needs are outlined in their person centred care plan and in a separate health action plan, which is maintained by people,which two people permitted us to see. The care plan detailed how staff provided support peoples and a personal profile was in place. Peoples preferred routines such as times of taking their shower and the support needs required by the people. Peoples likes and dislikes were also recorded. People are registered with a local General practitioner. We were informed that people are asked whether they wish to see male or female doctor and people can choose to visit their preferred dentist. Information seen during this visit indicated that people are supported by a range of health care professionals. A person with diabetes is supported by a diabetic nurse and Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: records to monitor their health were maintained. Another persons care plan identified that the home has liaised with speech therapy and occupational therapy in respect of their changing physical needs. Health action plans sampled indicated that people have received regular health screening checks and appointments, which was confirmed by records maintained including, visits to the chiropodist, optician and dentist. Staff have received specialist training ensuring that they are able to support the specialist health needs of people living in the service, which was confirmed by staff training records and discussion with staff at the time of this visit. Two health and social care professionals surveyed stated that peoples health care needs are always properly monitored, reviewed and met by the service and that the service always seeks advice and act on it to meet peoples health and social care needs. A health and social care professional said, The manager and staff strive to create a warm, welcoming and individual placement with care and quality for all of the residents. Two people spoken to during this visit said that staff respect their privacy and always knock on their bedroom doors. People have keys for their bedroom doors. During this visit staff were observed to be attentive, caring and addressed people respectfully. Three people spoken with during this visit spoke positively about the support they receive. Comments included, I am very happy living here and the staff are very nice and a person surveyed said, I am happy with everything here.Two health and social care professionals said that the service always respects privacy and dignity. During this visit we viewed the homes medication administration practises. People have now been provided with a lockable facility to enable them maintain their medication in their bedrooms. Currently people do not self administer their oral medication although one person is supported to self administer their insulin using an Epipen. We were informed that the service is intending to start supporting people with self medication. Two people invited us to visit their bedrooms and showed us their medication storage facility and their medication administration record, which were appropriately maintained and signed. Each person has a medication profile and protocols were in place for the administration of homely remedy medication Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: Medication is dispensed by a local chemist using the monitored dose system (MDS) Records were maintained for the receipt and disposal of medication. Staff receive medication training. which was confirmed by staff training records sampled and discussion held with staff during this visit. Care Homes for Adults (18-65 years) Page 18 of 30 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. If people have concerns they know how to complain and they are safeguarded from abuse. Evidence: We looked at information provided to people, which tells them about how they can make complaints. During this visit we saw a copy of the homes complaints procedure,which included the timescale for investigating any complaints and the contact details for the Commission. An accessible procedure is also available in the service guide. People are also provided with opportunities to raise any matters during home and monthly support meetings with their key workers. Five people surveyed said that they knew how to make a complaint. This was also confirmed by three people spoken with during this visit,who said that staff listen to their views. Three people said that would speak to the managers and staff. Records are maintained of both formal and informal complaints. No formal complaints have been received by the service over the last year. Complaints and concerns are also monitored through the organisations continuous improvement programme. The service has safeguarding vulnerable adults from abuse procedures in place including, the local authority procedure. During this visit we sampled three members of staffs training records,which confirmed that they receive regular training, although it was recommended that the person in charge of the home attends the local authority Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: safeguarding vulnerable adults from abuse training. Discussion took place with two members of staff, who were aware of their responsibilities should they ever witness or be made aware of any incident where the safety of people is compromised. Over the last year there have been no matters referred following the local authority safeguarding vulnerable adults from abuse procedures. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is safe, comfortable, homely and clean. Evidence: The service is an older style property that requires continuous refurbishment and redecoration. There is planned programme of maintenance and refurbishment in place. We were informed that maintenance has improved since the service has changed housing provider. Some tiles were missing in the downstairs, which the service had already reported. Information supplied in the AQAA stated that in the last year the kitchen and some bedrooms have been redecorated and lighting has been improved outside of the house. People living in the service are able to choose their preferred colour schemes. The home is spacious and provides a homely atmosphere. There is a large, comfortable lounge, a modern kitchen and separate dining area. The home has a large, well maintained garden to the rear of the property, which is enhanced with a decking area and garden furniture. This has been made accessible to people who may have mobility problems or use wheelchairs. Two people invited us to see their bedrooms, which were comfortable and personalised to their preference. However a down stairs bedroom visited felt cold, Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: which was confirmed by the person living there. This matter was brought to the attention of the manager. During this visit the home was observed to be cleaned to a good standard and was hygienic. Cleaning schedules and infection control procedures were in place. The manager has attended a two day health and safety course and we were informed that infection control is covered as part of staff health and safety training. Care Homes for Adults (18-65 years) Page 22 of 30 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. People using the service are supported by staff that are competent and trained to meet their needs and they are protected by the homes recruitment policies and practises. Evidence: At the time of this inspection there were two members of staff on duty both in the morning and in the afternoon. At night time people are supported by a sleep in member of staff and on call arrangements are in place. Information documented on the staff rota verified that that there are always two members of staff on duty. There are currently six members of staff employed by the service both full and part time. There has been minimal staff turnover in the last year. The home also uses regular staff from Mencaps bank team who know the people living in the service well. Information supplied in the AQAA states that five out of six carers employed in the service have obtained or are completing National Vocational Qualifications (Level 2) or above. New staff receive induction and foundation training following skills for care core induction standards. Discussion with a member of staff confirmed that they had received induction and they told us about the training courses that they had attended. Staff receive statutory training and receive a range of specialist training, which meets Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: the needs of people living in the service including, epilepsy and diabetes awareness. Two members of staff surveyed said that they have enough support to meet the individual needs of people who live in the home. Staff recruitment is based on equal opportunities. During this visit we sampled three members of staff personal files, which contained the required information including, completed application form, two written references and enhanced criminal records bureau checks (CRB) and protection of vulnerable adults (POVA) first check. However one persons file did not contain a second professional reference. This was discussed with the acting manager, who was aware of this matter which is currently being followed up. Staff receives regular formal supervision and appraisals,which was confirmed during discussions with staff, sampled and staff surveys. Care Homes for Adults (18-65 years) Page 24 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A permanent manager needs to be appointed who needs to be registered. The home is well run in the best interests of people living there, although the organisation needs to demonstrate that monthly quality monitoring visits are conducted reguarly by the registered person. Peoples wellbeing and safety is protected. Evidence: Since the last key inspection the registered manager has cancelled their registration with us, although they remain working in the service in a deputy manager capacity and they swapped roles with the previous deputy who is now running the home as the manager. It is required that the registered person submits an application to the Commission to register a manager with the Commission, which is required by legislation. Both the manager and deputy manager have worked in the service for a number of years and know the needs of people living in the service well. The manager currently holds National Vocational Qualification (Level 3) and the deputy manager had obtained the registered managers award. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: During this visit the manager and deputy were observed to have an open approach and made themselves accessible to both people using the service and staff. Staff spoken with said that they felt supported by management,there was good communication,the manager is approachable, there is good teamwork and regular meetings take place. Systems are in place to ensure that the views of people and their families are sought as part of the services quality assurance systems. Surveys were were supplied to people using the service,which are formulated in easy read format. We were informed that these are due to be updated. We also saw some of the surveys that were provided to relatives last year, which contained positive feedback. Surveys have been resent this year and the outcomes are waiting to be analysed. The organisation has a continuous framework that sets out how they promote quality assurance, which covers a wide range of areas, where compliance is assessed on a regular basis. Annual service reviews are also carried out and the outcomes are fed back into the continuous improvement plan. During this visit there were gaps in the monthly monitoring visits reports carried out by the registered provider (Mencap),which were not all available for viewing. Therefore it is required that these visits are carried out on a monthly basis and that the reports are maintained in the home and are made available for inspection. Staff training records sampled demonstrated that they receive regular statutory training including, first aid, fire awareness, food hygiene, moving and handling and health and safety. Records were maintained, which confirmed that regular water temperature monitoring is conducted and regular health and safety audits are carried out. The service maintains incident and accident records. Routine servicing and maintenance of facilities and equipment was up to date, which was confirmed by records sampled. Care Homes for Adults (18-65 years) Page 26 of 30 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 27 of 30 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 37 9 The registered person must make arrangements to ensure that a completed application is submitted to the Commission for the registration of a manager. This is to ensure that the home is run by a person fit to to do so 02/11/2009 2 39 24 The registered person must ensure that monthly unannounced, quality monitoring visits take place. This is to ensure that the home is being run in peoples best interests . 02/11/2009 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 23 It is recommended that the acting manager attends the local authority, multi agency safeguarding vulnerable adults Care Homes for Adults (18-65 years) Page 28 of 30 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 from abuse training. Care Homes for Adults (18-65 years) Page 29 of 30 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 30 of 30 - 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!