Inspection on 01/06/09 for Avondale Nursing Home

This inspection was carried out on 1st June 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avondale Nursing Home 06/09/07

Avondale Nursing Home 27/06/06

Avondale Nursing Home 06/02/06

Avondale Nursing Home 19/10/05

Avondale Nursing Home 22/12/04

Avondale Nursing Home 02/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 06/08/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Avondale Nursing Home Delphside Ltd 11 Sandstone Drive, Off Delph Lane Whiston Prescot Merseyside L35 7LS     The quality rating for this care home is:   two star good 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: John Mullen     Date: 0 2 0 6 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 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Avondale Nursing Home Delphside Ltd 11 Sandstone Drive, Off Delph Lane Whiston Prescot Merseyside L35 7LS 01514310330 01514300186 peterh@avondale.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Delphside Limited care home 50 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 50 Date of last inspection Brief description of the care home Avondale Care Home is a purpose built unit providing 24 hour nursing care for people with mental health problems. It is managed by Delphside which is a charity specifically formed to manage the home as a result of the closure of Rainhill Hospital. The registered manager is Peter Hamlett. The home is located in the Prescot area of Knowsley, close to Whiston Hospital and is easily accessible by road and public transport. It is on ground floor level and split into four separate units. All bedrooms are for single occupancy. There is also a substantial well maintained garden area Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 50 Brief description of the care home surrounding the home. The homes fees are 740.00 a week. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection of Avondale Care Home which included a visit to the service. All key standards were assessed in addition to a selection of other standards. This inspection encompassed information received since the last inspection including an Annual Service Review which was held on 6th September 2008. In addition it included information provided by the agency through its Annual Quality Assurance Assessment document (AQAA). The AQAA gives an overall picture of the performance of the agency as well as factual information about the service. Interviews took place with the registered manager, the deputy manager, four members Care Homes for Adults (18-65 years) Page 6 of 29 of staff including an activity worker, plus the financial manager, the catering manager, the head of the medicines management team and the housekeeping services manager. Four users of the service were case tracked that is their care was examined in detail and they were interviewed. In addition, other users of the service were interviewed at random. The premises were inspected and a large amount of documentation examined. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: The home needs to develop its training plan and ensure that this is implemented so that staff training is always refreshed in the required subjects. Within the context of a positive range of policies and procedures, it would be preferable if the Statement of Purpose was reissued so that all people living in the home have full information. Equally, reasons why some cannot have keys should be recorded in their care plans to emphasise the individualised approach to care. The home is very suitable for the care of residents but would be improved by the provision of a lockable facility in each bedroom so that personal items can be stored safely. Equally, fire drills would be better held twice yearly for the safety of all who are in the home. The home has a good structure for quality assurance but this could be Care Homes for Adults (18-65 years) Page 8 of 29 further developed to provide an overall direction for improvements to the home. Formal supervision of staff needs to be developed, including appraisals, to assist them to reach their full potential and to meet the objectives of the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The provision of full assessment material results in an appropriate and relevant plan of care. Evidence: The AQAA stated that full assessment material is present on admission so that work can be planned. An interview with the registered manager confirmed that he undertakes assessments and this supplements the material from the referring agencies, so that full background information is available. An examination of a selection of files of people who live in the home found a great deal of detailed, relevant information so that staff are informed of the background and needs of people who use the service. This was confirmed by interviews with staff who could show a close knowledge of the people they care for. 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. An individual programme of care is promoted in a safe manner. Evidence: An interview with the registered manager showed that the home is committed to an individualised approach to care based on care planning. An examination of a selection of the files of people who live in the home found a care plan in each which had been reviewed regularly to be both relevant and up to date. Interviews with staff confirmed they felt the care plans were effective in directing their work and also confirmed that they were regularly reviewed to ensure they remain up to date. Interviews with people who live in the home found that some were aware of the care plans and had attended meetings to review them. In all cases people interviewed were content that the care being provided in the home was in accordance with their needs. The AQAA stressed the use of monthly forums for people who live in the home so that they could give their views and effect change. The AQAA could give instances when this has happened showing that the input of users of the home has been positive. This Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: was confirmed by interviews with them who felt that they were assisted in making decisions as far as was consistent with their welfare. An interview with the finance manager showed that the management of service users monies was done in a correct manner so that a clear audit trail is available in the home. All users of the service who were spoken to confirmed that they were treated respectfully and they had no complaint about any restrictions on decision making within Avondale. The registered manager gave details of a strong commitment to the use of advocates so that people who live in the home can be helped in expressing their views. A review of evidence since the last inspection, including the Annual Service Review of this home, revealed no concern about the safe accommodation of people in the home. The registered manager confirmed that he has been trained in the area of risk assessments and is mainly responsible for implementing them to ensure a safe environment. An examination of files found risk assessments in each which were detailed, specific to the individuals concerned and had been reviewed regularly so that they were appropriate and comprehensive. Interviews with staff found them well aware of the risk associated with individual users of the service so that these could be minimised for their safety. 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. The individualised approach to care results in a pleasant lifestyle for people who live there based on individual choice. Evidence: Due to the illness of people who live at the home, relatively few have attended college or any adult education courses. However, the home does provide a wide range of activities to enable them to occupy their time positively. The home employs four specialist activity workers to implement a range of interests. An interview with one of these showed that there are problems of motivation but they attempt to overcome this with a varied programme to interest people. Interviews with people in the home found a wide range of attitude towards activities ranging from indifference to enthusiasm but all felt that the home does attempt serious efforts in this area. The home uses service user meetings as a means of engaging them in the area of activities and minutes seen of these meetings confirmed that their views are Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: respected. Interviews with users of the service confirmed that they used local facilities according to their own preferences. This was confirmed by both the listed activities in the home and by interviews with staff, including an activity worker. The registered manager said the home was well integrated into the local community and that the chairman of the local residents association was a frequent visitor and a supporter of home which further aided integration. The registered manager reported a good level of visiting from relatives which enabled people living in the home to remain in contact with their family. Interviews with people living in the home revealed no problem in this area and confirmed that they are free to visit relatives and receive visits as they so wish. Observations during the visit to the home found a generally pleasant interaction between people living in the home and staff confirmed relationships on the whole were positive. The last inspection made reference to the need to promote practice so that the privacy and dignity of people living in the home was promoted. Observations during this inspection were that staff behaved fully in accordance with these principles, including not entering bedrooms without permission. This was confirmed by interviews with people living in the home who felt they were treated respectfully. The home has no unreasonable rules so that people living there are unnecessarily restricted. The registered manager confirmed that keys are made available based on service users capabilities so that they have enhanced privacy. However, he did also state that when this is not the case due to the illness of the person involved, this is not individually recorded in their care plan which would be preferable in reflecting an individualised, non routine approach. An interview with the catering manager confirmed a very positive and healthy approach to the provision of meals within the home. This includes using local produce, including from the homes own gardens, so that healthy eating is promoted. This is underpinned by a good training of catering staff in nutritional matters and by a well equipped and appropriate kitchen area. Examination of menus in the home revealed a varied and nourishing diet is being provided. All people living in the home interviewed were content with the food on offer. Observations during the visit to the home of both a breakfast and lunchtime meal confirmed that food is served in a pleasant surrounding, resulting in a calm and sociable occasion. 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. The personal and healthcare support of people living in the home ensures that their individual needs are met. Evidence: All interviews with people who live in the home found them happy with the level of personal care being provided which they felt was in accordance with good practice. The home uses a key worker role for staff to promote an individualised approach to care and all people living in the home were aware of whom their particular key worker was, showing the effectiveness of the arrangements. The home employs a high proportion of qualified nursing staff which ensures that specialist care is provided when necessary. A tour of the premises found them well equipped to enable the personal care to be provided easily and effectively. Previous contact with this home has found that the individual health needs are promoted to ensure a healthy lifestyle. Examination of the files of people living in the home confirmed that the healthcare needs are assessed throughly and are attended to as required. The registered manager confirmed that a general practitioner visits the home weekly to attend people in the home and that the home has the support of Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: specialist psychiatric teams so that any problems can be addressed effectively and speedily. The home has a medicines management team to ensure a correct approach in this important area. An interview with the head of this team showed that she was given specific time to undertake this role, including liaison with general practitioners and chemists so that mistakes in this area are minimised. Documentation seen during the visit to the home showed the home has a full range of documentation to underpin practice. An examination of records recording medication taken in the home showed that these were correct to indicate good practice. 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. The policies and practices of the home, including the training of staff, ensure the safety of people who live in the home. Evidence: The AQAA stated there had been no complaint over the last twelve months and confirmed the home has an open approach to complaints so that these can be used as a learning tool. The deputy manager stated that the Statement of Purpose, which includes the complaints procedure, had been distributed to all people living in the home. However, a tour of the premises did not confirm this and the registered manager said he would redistribute this document so that all information is available to them. Interviews with people found they had no complaint to make about the home which they were very positive about. Typical comments included I like it and no problems. The Statement of Purpose had been reviewed in 2008 and was found to be of a good standard to provide basic information, including how to make a complaint. Recent contact with this home in respect of a safeguarding issue showed that the matter was dealt with appropriately and in accordance with good practice. The registered manager, confirmed by documents seen, emphasised that the homes policies are based on good practice to ensure that the safety of people living in the home is paramount. The deputy manager confirmed that training in this subject is given regularly to update staff knowledge. This was confirmed by training documents seen which showed that all staff, with the exception of one recently appointed, had Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: had training in the safeguarding of adults within the last twelve months to confirm the management statements. 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. The premises provide a safe and homely environment for the care of people living there. Evidence: The AQAA confirmed that there had been an improvement to the standard of the premises since the last inspection to enhance the living conditions of people residing there. A tour of the premises found them well suited for their purpose. The home is divided into four units with lounges that are pleasant and homely. All bedrooms are for single occupancy and were generally of the required standard to provide a satisfactory sleeping area. The one exception was that not all bedrooms had a lockable facility which is against guidance and was commented on by one person living in the home who felt that such provision would be very beneficial. Otherwise, the home is very pleasant and has particularly attractive garden area, including a vegetable patch, which adds to the decor of the premises. The home has installed an external CCTV system to enhance security and is constructing new smoking areas in the gardens for the convenience of people living in the home. The home is a generally safe environment which people living there spoken to were very happy to live in. One said I am happy to stay here. Within a safe environment, the home only conducts one fire drill a year which would be better increased to two for the increased safety of users of the home. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: A tour of the premises found it a clean and hygienic place for the care of people living there. An interview with the domestic supervisor confirmed that she has sufficient staff to maintain the standards of the home. It also revealed that she was happy with the equipment available to her for the same purpose. The home has a well ordered laundry room to maintain standards and is well equipped otherwise to ensure that hygiene is promoted. An interview with the registered manager showed that the home now has an infection control nurse and has used external training in infection control to promote standards in this area. 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. The home provides an effective workforce to care for people who live there. Evidence: The registered manager expressed great satisfaction with the quality and experience of the staff he has to promote the work of the home. A high proportion of the staff are qualified nurses to provide professional input into the care. In addition, the home has trained its care staff, including ten of the sixteen care workers to a higher level of a national qualification so that their practice is underpinned by sound training. Interviews with a variety of staff found them enthusiastic about their work and experienced in providing such care. They felt that the level of experience amongst the staff group resulted in the management of behaviour in a less challenging and more positive manner. People who live in the home who were spoken to expressed strong confidence in the staff group which they felt was approachable and supportive. An interview with the deputy manager confirmed that the home has a full recruitment and selection programme to ensure that suitable staff are appointed. An examination of staff files confirmed that all necessary checks on staff were in place, including police checks, to safeguard people living in the home. An interview with a recently appointed member of staff confirmed he felt the recruitment and selection process was fair and in accordance with good practice. A review of evidence has found no concern about Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: staff employed within this home. An interview with the deputy manager who takes a lead in staff training showed that induction training is provided systematically and to a good standard so that staff are prepared for their work. It also showed that staff training records are individually maintained to demonstrate training undertaken. The registered manager also produced a workforce development plan to confirm that this matter is considered systematically. However, although staff interviewed felt they were being well trained there were gaps in certain training areas including moving and handling and medication which showed that the training plan needs to be developed and implemented to ensure that staff remain up to date. An interview with the registered manager showed that the home was committed to meeting the guidance on supervision so that staff could be supported and developed. However, he did admit that the lack of management hours has impeded this. At the time of the visit to the service, the home was in the process of appointing a care coordinator which it was hoped would alleviate this situation. Interviews with staff found them very happy with the support they received but also confirmed that some shortage of formal supervision existed. This was confirmed by supervision documents seen which showed that the home is not always meeting its targets in terms of formal support. 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. The home is well managed in the interests of people living there. Evidence: There has been no change to the registered manager since the last key inspection. He has been in post since 2000 which has provided continuity to staff and users of the service alike. An interview with the registered manager confirmed that he has continued to undertake training to maintain his knowledge and skills. It further confirmed that he is clear about the aims and objectives of the home and this was confirmed by documents seen which showed that there is an organisational development process in place by which the home seeks to meet its declared objectives. Interviews with staff felt they were well supported in their work and a review of evidence concerning this home has revealed no problem with its management. The AQAA stated there was a need to improve the quality assurance procedures so that there was constant monitoring of the homes performance. During the visit to the home the registered manager also felt this was the case although he could show that Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: a structure was in place to develop this. This included regular meetings for people who live in the home to enable their views to be aired. It also included an annual development plan for the home with a organisational development process whereby the home attempts to involve all staff in meeting the stated objectives of Avondale. Documents seen during the visit to the home, included an evaluation of the performance of the home against the organisational objectives which showed that there was an attempt to gauge the homes performance. The registered manager conceded that these elements need to be consolidated into a full quality assurance system so that a method of continual improvement is reached. The registered manager stated that the homes health and safety performance is managed by a health and safety committee so that all aspects are considered. An interview with the chairperson showed that she and another member of staff have had specific training in this area to underline their competence. She could show that an annual health and safety audit is undertaken to promote safety in the home and that the meetings of the health and safety committee are frequent and consider all relevant safety matters. This was confirmed by minutes of these meetings seen during the visit to the home. The visit also included confirmation that checks of utilities are made in accordance with good practice to confirm a safe service. Training documents seen confirm that training, including at induction, is given in safety matters to reinforce staff competence in this area. A tour of the premises found no matter of concern about the safety of staff or people living there. 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 1 35 18 The training plan must be developed. To ensure that all staff are regularly updated in the required subjects. 01/09/2009 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 16 Where people who live in the home are not provided with keys the reasons for this should be detailed in their care plans to show an individualised approach. The Statement of Purpose should be reissued to people living in the home so that they have full information, including in the area of complaints. Each bedroom should have a lockable facility to further safeguard personal belongings. The home should conduct two fire drills a year for the further safety of staff and people living in the home. Formal supervision of staff needs to be increased so that they are further developed in their work. The quality assurance programme needs to be brought together so that a clear picture of development is Page 27 of 29 2 22 3 4 5 6 24 24 36 39 Care Homes for Adults (18-65 years) 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 produced. Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!