Inspection on 03/09/09 for Ayeesha-Raj

This inspection was carried out on 3rd September 2009.

CQC found this care home to be providing an Adequate 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ayeesha-Raj 30/08/07

Ayeesha-Raj 20/04/06

Ayeesha-Raj 16/01/06

Ayeesha-Raj 02/06/05

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 25/11/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Ayeesha-Raj 86 Loughborough Road Mountsorrel Leicestershire LE12 7AU     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: Ruth Wood     Date: 0 3 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 32 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 32 Information about the care home Name of care home: Address: Ayeesha-Raj 86 Loughborough Road Mountsorrel Leicestershire LE12 7AU 01509413667 F/P01509413667 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Cherre Residential Care Ltd care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Ayeesha Raj is a care home for 20 people with learning disabilities. Ayeesha Raj is on the main road running through Mountsorrel. It is close to the centre of the village. It has good access to public transport services to Leicester and Loughborough. It is a large, detached house. There are 16 single bedrooms and 2 bedrooms for 2 people to share. It has three living rooms on the ground floor. The garage has been converted into a games area for service users. There is a patio garden and off road parking for staff and visitors. Copies of inspection reports are kept in the office for people who live in the home and members of the public. 20 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 32 Brief description of the care home It costs between £344 and £347 to live at Ayeesha Raj. Care Homes for Adults (18-65 years) Page 5 of 32 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: Before we visited Ayeesha Raj, we looked at the information the provider had sent us in the Annual Quality Assurance Assessment. This is a document that tells us about how Ayeesha Raj is run and the kind of people who live and work at Ayeesha Raj. We looked at information sent to us about what has happened at Ayeesha Raj since we last visited on 30 August 2007. We sent surveys to 9 people living at Ayeesha Raj. 8 people replied to our survey. We asked if people are happy with the care and support in the home. We sent surveys to 5 staff working in the home. 4 staff replied to our survey. We asked about the training they get. We asked about the support they get from managers. Care Homes for Adults (18-65 years) Page 6 of 32 We visited Ayeesha Raj on 10 September 2009. We arrived at 10 oclock in the morning and left at 5 oclock in the afternoon. We looked at some of the rooms in the home We spoke to 12 people who live at Ayeesha Raj. We looked at 3 peoples support plans We spoke to staff about how they support people. We spoke to staff about the training they had done. We looked at staff records. These told us about the checks done to make sure staff have the right skills and are safe to work in the home. Care Homes for Adults (18-65 years) Page 7 of 32 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. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 32 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Easy to read information is available about the service, which helps people to decide if the service can meet their needs. Peoples assessments are not always updated to reflect their current needs. Evidence: During a thematic inspection of the service (which took place on 14/08/08 and focused on how the service managed safeguarding) we identified that the service had admitted two people out of their registration category, who had a primary need of mental ill health rather than learning disability. The two people had their placements terminated as the service could not meet their needs. The acting manager and provider were warned that admitting people outside of their registration category was an offence they can be prosecuted for under the Care Standards Act 2000. The acting manager said that there had been no new admissions to the home in the last 6 months but had outlined the assessment and admission procedure in the Annual Quality Assurance Assessment. This states that the service will conduct their own assessment of the person which includes consulting with professionals and existing Care Homes for Adults (18-65 years) Page 10 of 32 Evidence: carers. Their compatibility with other service users will be monitored during day and overnight visits to the service. The care files of the three people whose care we looked at in detail did contain assessments of their needs, as well as information from other professionals involved in their care. Two out of three of the assessments required updating to more accurately reflect peoples current needs. People who live at Ayeesha Raj have produced an easy-read service user guide, with pictures; this gives people who are thinking of moving to the home information about what it is like to live there. Half of the people living in the home who responded to the Commissions survey said that they got enough information about the home before they moved in. Care Homes for Adults (18-65 years) Page 11 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Support plans do not give staff sufficient information about how to meet peoples needs, enable people to make choices and understand how to minimise and manage risk. Evidence: We looked at three peoples care needs and how they are met. This involved spending time with the person and communicating with them, speaking to staff about the support they gave the person and looking at written support plans and other documentation in their care files. Assessments were not always an accurate reflection of peoples current needs and support plans did not give clear and detailed information to staff about how they should meet peoples needs. The exception to this was in relation to physical health care (please see personal and healthcare support) and in one persons support plan which had been recently updated. The other two plans did not give sufficient guidance to staff; for example one plan stated educate X not to take anything that does not belong to them, but did not say how or why this should be done. It did not, for example, identify any risk to the person themselves, or to Care Homes for Adults (18-65 years) Page 12 of 32 Evidence: other people, in this behaviour. Discussion with two staff members and observation of staff practice, indicated that there was no consistent approach to this issue. One person had particular communication needs arising from their learning and sensory disabilities. There was no clear plan in place about how to communicate with this person, although staff were able to show us cards with symbols and pictures which they said they used to communicate with the person (we did not directly observe this taking place). One staff member said that they would show the person the actual objects when trying to get them to make a choice. Again this was not detailed within their plan and it was difficult to ascertain if this approach was used consistently by all staff. This persons needs had recently changed significantly and assessments and plans had not been updated in all areas. There were no specific risk assessments in place in relation to people travelling or being supported outside. It was unclear from looking at support plans as to the level of support people required outside of the care home when undertaking social activities. Care Homes for Adults (18-65 years) Page 13 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to participate in a variety of activities, which take account of their needs and interests. Evidence: People living in the home are positive about the food; six out of the eight people who responded to our survey said that they always or usually liked the meals, The food is good, They make sure we have good cooked meals. Menu records show that people have a choice of what they can eat and that a balanced diet is served. One person said that they would like to do more cooking themselves. On the day of the inspection six people were at specialist day services for people with learning disabilities, either in Mountsorrel or Loughborough. When they returned home they spoke positively about going to the day centre, I enjoy it, its nice there, have you been?. Two people attended a specialist Art Project with the support of a staff Care Homes for Adults (18-65 years) Page 14 of 32 Evidence: member from Ayeesha Raj. Again they were positive about this setting and the activities they took part in such as painting, drawing and making things. One person who lives at the home is in paid employment. Some people do not have a formal day time activity every day but stay at Ayeesha Raj and watch television or listen to music. Some people are able to go out independently to nearby towns, such as Loughborough, using public transport. People living in the home said that they hadnt been on holiday that year but had been on a day trip to Skegness. Some people said that they had been to a special disco for people with learning disabilities, the previous evening called, Half Time Orange. Other activities that people spoke about were going out for meals and going bowling. Only one relative responded to our survey; they said that they are usually kept up to date with information about their relative but we didnt ask people specifically about how they remained in contact with their families. People have keys to their own rooms and most people keep their rooms locked. Staff do not enter their rooms without permission. Care Homes for Adults (18-65 years) Page 15 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs are well met. Evidence: Peoples personal care needs are outlined in their support plans although these would benefit from some additional detail as to peoples personal preferences about how their needs are met. Peoples appearance and general demeanor did indicate that their personal care needs are being met and they are supported in getting their hair cut, buying clothes and taking a pride in their appearance. Health Action Plans were in place for each person whose care and support needs we looked at in detail. Grab sheets were also in place, containing all essential healthcare information about the person; these are used if the person needs to be admitted to hospital in an emergency. Care plans are in place outlining how to manage peoples diabetes; these included arrangements for regular testing of blood glucose levels and how staff should respond should levels fall outside the optimum range. Each person living at the home has an annual health check at their local health centre and we saw from looking at records and speaking to people living in the home that Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: they have regular access to dentists, chiropodists, opticians and other healthcare professionals, such as psychiatrists and speech and language therapists. We looked at medication administration; all medication administration records were accurately completed and each contains a photograph of the person so that staff are clear about which record belongs to which person. All staff that administer medication have received appropriate training and an additional staff member also countersigns the record to confirm that medication has been administered correctly. Amendments to Regulations relating to the Misuse of Drugs mean that the home must have separate storage for controlled medication. This should be a metal cupboard of specified gauge with a specified double locking mechanism. It should be fixed to a solid wall or a wall that has a steel plate mounted behind it with Rawl or Rag bolts. No controlled medication is currently stored or administered in the home. Care Homes for Adults (18-65 years) Page 17 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good systems are in place to encourage people living in the home to voice their concerns and complaints. Because the service does not consistently monitor peoples needs and ensure that they receive sufficient levels of support to meet them, other people living and working in the home may be placed at risk from their behaviour. Evidence: People living in the home know that if they are not happy they can make a complaint to staff. An easy to understand version of the complaints procedure is posted on notice boards around the home and each person living at Ayeesha Raj has their own copy. When we asked one person what they would do if they werent happy with anything in the home they said, you tell the staff, it tells you how to do it on the back of my door. Everyone we spoke to appeared clear about the procedure and people are also encouraged to voice their concerns at the monthly residents meetings. Every complaint or concern raised is recorded, together with the action taken to resolve the complaint. Staff records show that staff receive training in safeguarding and the two staff we spoke with confirmed this and displayed a good understanding of when they would report concerns and who to. One staff member was a little unsure as to the detail of the arrangements in place for whistleblowing, and the practicalities of reporting any concerns to outside agencies if staff feel that the service is not taking appropriate Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: action. It is recommended that the homes whistleblowing policy be reviewed to ensure that it contains information about the Public Interests Disclosure Act and the charity Public Concern at Work. The Act protects people who make disclosures in good faith and the charity can offer them independent support when doing this. The details of the whistleblowing policy should be reviewed at staff meetings. Since the previous Key Inspection there have been a number of incidents where people living in the home have become distressed and/or their behaviour has become so challenging that police intervention has been sought. Information about these incidents has been well documented and the appropriate agencies, including social services and ourselves have been informed. During this inspection visit, some staff members and some people living in the home expressed concern about the behaviour of one person currently living at Ayeesha Raj and how this can impact negatively on others. We discussed this after the inspection visit with the registered provider, and the service is currently seeking additional support from outside professionals to more successfully manage this persons behaviour. The registered provider informed us about an incident in which this person had recently hit two other people living in the home and the police had to be called. While it appears that the response to this incident was largely appropriate the registered person must seek to more actively keep peoples needs under review and ensure that their support plans give staff clear guidance on how they should be met (see Individual Needs and Choices Outcome Group). This should include a review of the staffing levels required to meet peoples needs and ensure that other people living in the home remain safe (please see Staffing outcome group). Staff said that they had received training in NAPPI, that is Non- abusive psychological and physical intervention, but felt that they would also benefit from additional training in to the reasons why people may present with behaviour that challenges. We looked at systems in place for managing peoples finances; transactions for each person are recorded and balances of money held is checked twice per day to ensure that they are accurate. The precise arrangements in place for obtaining and storing money from the bank were unclear from the acting managers description and we asked the registered person to outline these in writing for us. They provided this information for us before the publication of the final report. Care Homes for Adults (18-65 years) Page 19 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and peoples bedrooms reflect their individual tastes and personalities. Some improvements are needed to the homes environment so that all areas are pleasant to live in and are suitable for the needs of the people living there. Evidence: We looked at all the communal areas of the home and some peoples bedrooms. Most people keep their bedrooms locked and did not want us to look inside their rooms. Some people did invite us into their rooms and the rooms we saw were personalised and reflected the activities and interests of the person. There was black mould on water pipes in one persons bedroom and on pipes in the corridor in the old part of the building on the first floor. The wallpaper was also coming away from the wall in the same area of the corridor. We spoke to the registered person about this who assured us that the home did not have a damp problem but that there had been a leak from a header tank in this area. She said that she would ask the homes maintenance worker to wash down the pipes and to repair/redecorate the area as necessary. We noted that there were no blinds or window coverings in any of the homes Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: bathrooms, which compromises peoples dignity and privacy when bathing. All areas of the home that we viewed were clean and fresh smelling and the registered person said that female staff have received recent training in infection control as part of a government initiative to made training available to the female workforce. The environmental health officer undertook a food hygiene inspection of the service on 23/03/2009 and awarded a rating of two stars, adequate. A requirement was made to remove wallpaper from the kitchen walls and to repaint the area; this has been completed. A fridge with a faulty seal still required replacement at the time of our inspection, but the registered provider has assured us that this has been ordered and will be delivered to the home on 11/09/09. Care Homes for Adults (18-65 years) Page 21 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are needed in the numbers of staff and their levels of training to ensure that people living in the home are consistently supported and have all their needs met. Evidence: We looked at the staff rota for the week of the inspection visit and the week preceding and following the visit. We also spoke to staff and to people themselves about their needs and how staff meet them. Staff members and records kept in the home told us that two of the eighteen people currently living in the home can present significant challenges that require one to one input from staff, sometimes for a sustained period. One of these people has scheduled one to one time for which additional payment is made by their placing authority. For significant periods of time there are only three staff members on duty. On the three weeks rota that we looked at, this routinely takes place between 6pm and 10pm in the evening during weekdays, between 3pm and 10pm on Saturdays and Sundays and all day during the recent bank holiday. Staff commented during our inspection visit that it was difficult to manage if both people who require one to one support required it simultaneously. The rota also shows that on some weekday mornings, there are between three and five staff members on duty, in addition to the acting manager to support people taking part in day time Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: activities. The registered person should review the level and deployment of staff to ensure that it is sufficient to meet peoples changing needs at all times. We have been informed that funding has been sought for additional staffing in the home. We looked at the training and recruitment records of three staff on duty at the time of the inspection visit, and spoke to a further two staff members about their experiences of recruitment and training at Ayeesha Raj. References were not on file for two people. One persons were faxed through to the home from the companys head office during the inspection visit. The other person is placed at the home as part of the modern apprenticeship scheme and the placing orgnisation has not forwarded copies of their references. The registered person contacted the organisation during our visit to obtain copies of these references; copies of these were forwarded to the Commission as they were not available on the day of the inspection. Evidence of a Criminal Records Bureau check was not available for one person; this was faxed to the home during the inspection visit. Staff spoken with said that references had been obtained and Criminal Records Bureau checks completed, before they started work in the home. Staff files contained evidence that people had received training in Safeguarding NAPPI (non- aggressive psychological and physical intervention.), health and safety and epilepsy awareness. Some staff have also received training in administering emergency medication for people with epilepsy. Two staff on duty during the inspection visit said that they had not received any specific training in working with people with learning disabilities and no staff working in the home have received training in understanding associated mental health conditions. This is despite the fact that some people living in the home have mental health conditions in addition to their primary need of learning disability. There is no planned system in place for staff to acquire qualifications (such as the Learning Disability Qualification) in working with people with learning disabilities although the registered provider said that she had recently been in contact with the local authority so that the service was informed of free training that they could access. Following the inspection the registered person informed us that staff training in mental health and in learning disability had been arranged for for dates in October and November. We will monitor this at a random inspection later in the year. Staff may also benefit from specific training in communicating with people with sensory disabilities, so that they can meet the additional needs of some of the people who currently live in the home. Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: There is written evidence on staff files to demonstrate that they receive supervision with the acting manager or registered person on a regular basis and the two staff we spoke to during the inspection visit confirmed this. We asked the register person to provide a risk assessment in relation to one staff member who has some health care needs; the registered person agreed to do this. Care Homes for Adults (18-65 years) Page 24 of 32 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. More consistent management is required to ensure that staff have clear direction and that peoples needs are kept under review and met consistently. Evidence: Ayeesha Raj has been run by the current owners, Cherre Residential Care since April 2005. During this time there has been no registered manager in the home. A thematic inspection of the service, which focused on safeguarding which was made in August 2008. A timescale of 01/12/08 was given for a registered manager to be in place. This has not been met. A new acting manager was recently appointed who worked at Ayeesha Raj between July and mid August 2009 before leaving without giving notice. The assistant manager has now been promoted to acting manager and is now in day to day charge of the home. Although this manager has a general nurse qualification, they do not have any qualifications in learning disability or management. The acting manager said that they intend to begin a course of training in both these areas from September. We asked the registered person to write to us, giving a clear timescale as to when this person Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: will be put forward for registration, and the support and training they will be offered until that time. The registered person has provided this information. As outlined in previous outcome groups some aspects of the ongoing management of the home require improvement; primarily care planning, staff deployment and training. During the inspection visit the acting manager and provider had difficulty locating information that we wanted to see. Some of this was faxed from head office, but some (such as the most recent Quality Assurance information) could not be found. Staff also appeared to lack some direction, seeking advice from the inspector as to who should conduct a handover. People living in the home are consulted about their views through annual questionnaires and regularly asked for input about the running of the home at monthly residents meetings. Documents displayed on the office notice board demonstrate that Fire systems and equipment have been serviced. During the inspection visit the fire alarm was sounded and the building evacuated successfully. The fire risk assessment was updated on 20/03/09 and a copy has been sent to the Leicestershire Fire Service. Care Homes for Adults (18-65 years) Page 26 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 37 8 Confirmation must be received detailing the action being taken to register a manager for the home. There is an acting manager in place but she has not applied to become registered yet. Timescale of 01/12/07 not met. This matter will be brought to the attention of the link inspector for the service for consideration of further action. 14/05/2008 Care Homes for Adults (18-65 years) Page 27 of 32 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 2 14 The registered person shall 30/11/2009 ensure that the assessment of the service users needs is kept under review and revised as necessary This is to ensure that the assessment remains an accurate reflection of peoples changing needs and the service is able to monitor its ability to meet peoples needs. 2 6 15 The registered person must ensure that each service users plan outlines how staff should meet their identified needs. This is to ensure that peoples needs are met in a consistent way by all staff members 30/11/2009 3 6 15 The registered person must ensure that each service users support plan is regularly reviewed and 30/11/2009 Care Homes for Adults (18-65 years) Page 28 of 32 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 updated to reflect the persons changing needs. This is to ensure that the plan accurately reflects what a persons needs are and how they should be met. 4 9 13 The registered person must ensure that any activities in which service users participate are so far as is reasonably practicable, free from avoidable risks. They must ensure this by identifying potential risks and stating clearly in the form of written plans how these should be managed. This is to ensure that people can take reasonable risks without experiencing unnecessary harm or their freedom being unnecessarily restricted. 5 20 13 Secure storage must be put in place for controlled drugs to meet the requirements of the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007 To ensure that controlled medication is stored in a safe way that complies with current legislation 31/12/2009 30/11/2009 Care Homes for Adults (18-65 years) Page 29 of 32 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 6 24 16 The registered person must ensure that all bathrooms have suitable window coverings. This is to ensure the privacy and dignity of the people living in the home. 31/10/2009 7 32 18 The registered person must 30/11/2009 make provision to ensure that staff receive training appropriate to the work they are to perform. This is to ensure that staff have the skills necessary to meet peoples assessed needs. 8 33 18 The registered person must 30/10/2009 ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This is to ensure that people living in the home have their needs consistently met at all times. Care Homes for Adults (18-65 years) Page 30 of 32 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 The homes whistleblowing policy should be reviewed to ensure that it contains information about the Public Interests Disclosure Act and the charity Public Concern at Work. Staff should be reminded about the content of policy at staff meetings and their responsibilities under it. Care Homes for Adults (18-65 years) Page 31 of 32 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. 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