Inspection on 08/12/08 for Chapel Street Care Home

This inspection was carried out on 8th December 2008.

CSCI 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

Chapel Street Care Home 16/10/06

Chapel Street Care Home 13/10/05

Chapel Street Care Home 25/04/05

Chapel Street Care Home 17/12/04

Chapel Street Care Home 04/05/04

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 29/01/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Chapel Street Care Home 3-5 Chapel Street Kirkby In Ashfield Nottinghamshire NG17 8JY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Andrew Bailey     Date: 0 8 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.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: Chapel Street Care Home 3-5 Chapel Street Kirkby In Ashfield Nottinghamshire NG17 8JY 01623757902 01623720988 Denise.Pendleton@mencap.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Royal Mencap Society care home 9 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Royal Mencap Society is registered to provide accommodation and care at Chapel Street Care Home for up to 9 persons of both sexes whose primary needs fall within the following category: Learning disability LD (9) Date of last inspection Brief description of the care home 3 - 5 Chapel Street provides accommodation for nine service users with a learning difficulty. The accommodation is not accessible to wheelchair users. It comprises two adapted joined houses with three floors, including a self-contained flat. The home is situated in a residential area, with good access to local shops, pubs and transport. There is a garden to the rear of the property. The service users are encouraged to be as independent as possible with staff support. The fees at the time of the inspection were £282.95 to £579.22 per week. 9 Over 65 0 Care Homes for Adults (18-65 years) Page 4 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: 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 last inspection of this service was on 16 October 2006. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service. The process considers the homes capacity to meet regulatory requirements and minimum standards of practice. The inspection visit was unannounced and took place over a 5 hour period. There were nine people living at the home on the day of the inspection. Three residents, staff, and the registered manager were spoken with during the visit. Care Homes for Adults (18-65 years) Page 5 of 30 We also looked at information that we have received since the last inspection. The information included the Annual Quality Assurance Assessment (AQAA) that was sent to us by the service. The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. The service has also told us about things that have happened at the home and these are called Notifications. We have considered the nine surveys that have been completed by people using the service and their views have been included in this report. Records were examined during the inspection, including the care records of three of the people who live at the home. This was part of the process called case tracking. Where possible we spoke with these people during the inspection visit. What the care home does well: What has improved since the last inspection? What they could do better: The care planning documentation should include falls risk assessment and nutritional screening for any older persons living at the home. Minor amendments to the homes written safeguarding policy and procedure should be undertaken to ensure it fully reflects local multi-agency guidance. There are good quality assurance and quality monitoring systems in place and the system could be further improved by exploring ways to share the results of satisfaction surveys with current and prospective users of the service. Care Homes for Adults (18-65 years) Page 7 of 30 A requirement has been made to obtain written confirmation that the fixed electrical wiring is in a satisfactory condition, following extensive rewiring in 2006. This is not indicative of a shortfall in the local management of the home. It presents more as a matter of the communications and relationship between the service provider and the landlord of the property. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 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 9 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 who use the service receive information to help them decide whether the service can meet their needs, and have the opportunity to visit the home before choosing to live there. Evidence: In the Annual Quality Assurance Assessment (AQAA) that we received before this visit the service told us that pre-admission stays and visits are available to people who are considering living at the home. They told us that there is accessible written information in a suitable format to meet the varying needs of people. Families and carers are included in the admission process, and other professionals such as members of the Community Learning Difficulty Team (CLDT) are also involved. There have not been any recent admissions to the service, the most recent having taken place in 2005. The registered manager explained the admission process that took place for this admission and would also be relevant for any future prospective persons who might consider living at Chapel Street. We were able to examine the Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: documentation for the person most recently admitted to the service and this was satisfactory. The person had visited the home on several occasions and had undertaken overnight and weekend stays before deciding to live at the home. The CLDT team had referred the person for potential admission and had been involved in ensuring that the person subsequently settled at the home. We received survey information from the nine people living at the home. All said that they had been asked if they wanted to move into the home and stated that they had received enough information about the home before they moved in so that they could decide if it was the right place for them. We spoke with three of the people living at the home when we visited to inspect the service. People confirmed that they felt involved in the process of deciding whether the home was right for them. The home has a Statement of Purpose and Service User Guide. We looked at these documents and we found that they were in a suitable format, which included the use of photographs, and that they had been reviewed and updated recently. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning process ensure that the needs of people are recorded in their care plans, and that there is guidance for staff to follow to help them to support the people living at the home. Evidence: The service told us in their Annual Quality Assurance Assessment (AQAA) that multidisciplinary reviews take place annually for the people living at the home. They told us about the training that takes place with people, which helps to support them and maintain their safety. The training covers things like fire safety and safe cooking skills. They told us about how they use the recording systems to demonstrate that the Mental Capacity Act 2005 is considered when looking at the competency of people in making their own decisions. Some staff have attended training on the Mental Capacity Act, with others booked to attend in the new year. The manager has also attended training about Deprivation of Liberty (Mental Capacity Act 2005). The service said that they maintain person centred care records about the people living at the home. Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: We case tracked three of the people living at the home. This included looking at the care records held about them. We could see that there is regular review of the content of the records to ensure that the person centred plans are up to date. Staff and people living at the home had signed to acknowledge agreement with the care records and risk assessments, and any subsequent changes to the plans had also been signed. The manager told us that in one instance, a parent of a person living at the home signs on behalf of the person living there. The care records demonstrate that people living at the home (and where appropriate relatives and carers) are directly involved in the care planning processes that the home undertakes. The support care plans were detailed and included plans for health and social needs. A keyworker (staff) is allocated to each person living at the home, but people are encouraged to approach any member of staff with issues that they may wish to discuss, rather than waiting for a specific member of staff to come on duty. There was evidence in the care records of the annual multidisciplinary reviews. The manager told us that the reviews are arranged by the Reviewing Officer (CLDT team) or by the social worker, where allocated. The reviews are combined day centre and home placement reviews. There are three main documents held for each person living at the home, a Service User Guide and Person Centred Plan, a health file, and a finance file. We were able to see that consideration is given to the competency of people to make their own decisions, in line with the Mental Capacity Act 2005, with written assessments included in the care plan documentation. The assessments had been reviewed monthly, and covered decision making for matters such as medication and finances. The manager told that she is continuing to look at how competency assessments are recorded and examining ways that this can be further developed. When we spoke to people living at the home and looked at the surveys completed by them (sometimes with the help of staff or a relative) it was confirmed that people feel that they are able to make their own decisions as far as is possible for the individual. They also feel supported by the staff. Comments from people living at the home included: There is good staff; they look after us well, and I can talk to staff. 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 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 lead a lifestyle of their choosing, ensuring that their individual goals and life expectations are promoted. Evidence: In the AQAA self assessment that we received before this visit the service told us about the leisure records that are kept on behalf of the people living at the home. They told us about how the rear garden area had been developed and the input that the people at the home have had in this project. The service described the system for arranging holidays for people and the day-to-day activities and work opportunities. They also stated that they place emphasis on supporting people with daily living skills, for example, the role of people in menu planning. At the inspection the manager told us that seven of the nine people living at the home Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: attend the local day centre. Attendance currently ranges between two and five days per week per person. Two of the people at the home undertake paid employment, with one person working two mornings per week and one person working three days per week. On days when they are not attending the day centre or employed, people exercise choice in how they spend their time e.g. shopping, undertaking other social activity or cleaning their rooms. In the evening people at the home tend to meet in the communal area to eat as a group . This was the case on the evening of the inspection visit, when we were able to meet most of the people who live at the home. One evening per week many of the people attend a social club, for which transport is provided. At other times staff support people to be a part of the community if they wish to go out, for example visiting the pub or playing snooker. There are some people at the home who are quite independent. For example, two of the people at the home frequently enjoy day trips and holidays independent from staff. Each person has a holiday file with details of holiday planning, costings and records of the holidays taken. Individual records of social and leisure activity on a day-to-day basis are also held for each person living at the home. We we able to examine the records relating to lifestyle during this inspection and where possible we did this as part of the case tracking methodology, so that we followed the specific experiences of three of the people living at the home. There is a family charter in operation, with a quarterly newsletter to family describing what the person living at the home has done and their future plans. A member of staff assists individuals to compile these letters. The manager told us that many of the relatives find the newsletter very informative and have expressed appreciation since the system was introduced. People are supported where they wish to have relationships. Specialist support is available from outside agencies, if this is required or appropriate. We saw documentary evidence of where a Nottinghamshire Healthcare Community Nurse from the Community Learning Difficulty Team had provided specialist advice about relationships to one of the people living at the home. With respect to catering, people living at the home are involved in producing the menu for each week and participate in shopping for the goods with support from staff. Many of the people at the home prepare their own snacks and some help with preparation of the main meals, depending on their wishes and abilities. All staff have undertaken food hygiene training and the service maintains records of food consumed at the home. People we spoke with and feedback from the surveys confirmed that people living at the home feel that they are able exercise choice about their lifestyles, whilst receiving support from staff where needed. Comments included: I like living here. Care Homes for Adults (18-65 years) Page 15 of 30 Care Homes for Adults (18-65 years) Page 16 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive suitable personal and healthcare support through a system of assessment and monitoring that involves people as partners in their care. Evidence: The service told us in their Annual Quality Assurance Assessment (AQAA) that a multidisciplinary working approach is utilised. People have regular well-person checks from the primary healthcare team and each person has personal support plans in place. Staff receive training about medications and there are audit systems in place to provide a safe service to people using the service. We case tracked three of the people using the service. We found that there were detailed care records in place. The documents included record of contact with other health professionals. There had clearly been consultation with people using the service and they had signed to signify their agreement with their personal care plans. All staff had signed to acknowledge that they had read the care plans and this included any changes that were applicable following the monthly review process. When we spoke with people they were able to confirm that they had been involved in the care planning Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: process and felt that they were well supported by staff. One said: The staff are great and help me a lot. A hospital book is compiled for each person living at the home. These documents contain useful summary information about individuals in the event that hospital attendance is necessary. For example, there is information about their needs, communication, likes and dislikes, and previous medical history. One of the persons living at the home is over 65 years. The manager is applying the older person National Minimum Standards in this instance. This person lives a relatively independant life at the home, but notwithstanding this we noted that the care records did not contain detailed and specific risk assessment of the risk of falls and there had not been nutritional screening. We discussed this with the manager and she has agreed to review the records so that anyone of sixty-five years or over benefits from the same standard of assessment as should be the case under the National Minimum Standards - Care Homes for Older People. Requirements relating to medications from the last inspection have been fully addressed. We looked at the system for handling medications and this was satisfactory. Records of administration were clear and detailed and there was suitable resource information available for staff to refer to. 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. The home responds appropriately to any concerns and complaints and aims to protect people from harm. Evidence: The AQAA self-assessment that we received prior to the inspection told us that staff have received training in the protection of adults (safeguarding training). They stated that the in-house training for people living at the home includes how to complain and also covers dealing with incidents of bullying. We spoke with a member of staff who confirmed that safeguarding training had taken place. We confirmed that the home has a policy and procedure for handling abuse, or allegations of abuse. The service has the local multi-agency referral procedures and associated guidance. However, although the homes guidance is generally satisfactory it could be interpreted in a way that could be in contradiction to the multi-agency guidance with respect to information gathering in the event of an allegation of abuse. We discussed this with the manager and she undertook to review the homes document. She also agreed to display the safeguarding contact information more prominently in the event that staff needed to make a referral out of hours. The manager and a staff member told us that staff had been trained in de-escalation techniques since the last inspection, to further equip them to deal with any incidents of Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: challenging behaviour. We spoke with people who use the service and together with responses from the written surveys the feedback suggests that there is an open culture where people feel at ease in raising any concerns that they may have. One person said: I know who to speak to. We examined the complaints information log. There had been three complaints in the past year, two of which related to conflict between two of the people living at the home. All complaint issues had been suitably addressed, resolved and dealt with within the recommended timescales. The Community Learning Difficulty Team had been informed of all three cases, which further demonstrates the open culture at the home. The complaints procedure is included in the Statement of Purpose and the Service User Guide provided by the service. 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. The home provides a safe, comfortable, and homely environment for the people living there. Evidence: In the self assessment that we received from the service before the inspection they told us that the conservatory had been made more comfortable with the purchase of new dining chairs, a settee and new carpeting. When we inspected they also told us about the air conditioning that had been installed in this communal area. The service also told us about the development of the rear garden area, which includes a place to grow produce and a fish pond. They stated that they plan to introduce raised beds in the produce area of the garden. The manager told us that one of the barriers that the service faces is that whilst Mencap manage the service, the property is owned by a housing association, which means that the service provider has indirect control over the upkeep of the property. In the self assessment the service told us that there have been issues over decoration and repairs. The service confirmed that staff have received training in infection control measures. People told us that they choose the decoration for their bedrooms and one of the people at the home was pleased to show us their room and explain how they had been Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: able to decorate and personalise it to their own choosing. When we toured the building we found that it was clean and tidy, but some areas of the home were in need of redecoration and/or refurbishment, such as the tiled area in the shower room. The manager is well aware of the areas that need improving and is using her best efforts to ensure that pressure is applied in order that the housing association progress the work. When we spoke with people and looked at the written survey responses we found that people consider the home meets their needs and one person commented The home is always fresh and clean. People living at the home undertake their laundry, with the use of a domestic washer and dryer. Each person has an agreed specified day to launder their own items. We spoke to a member of staff who was able to confirm that infection control training had taken place. There are also written policies and procedures for staff to refer to when needed. There has recently been an inspection by the fire officer (22 October 2008) and arrangements have been made to address the recommendations from the report. This includes the fitting of fire retardant strips to some of the doors. 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. Staff training and robust recruitment practices promote the safety of people living at the home. Evidence: In the AQAA self assessment that we received the service told us that equality and diversity is reflected in their recruitment practices and that there are thorough staff recruitment checks to protect the people living at the home. Staff receive induction and a range of on-going training to equip them to support people and promote their safety. The service told us that most of the staff have completed National Vocational Qualification (NVQ) training and one person is in the process of studying for this. They told us that there are low levels of sickness among the staff. The home is staffed by a manager with the support of five full-time and 2 part-time staff. We spoke to people during the inspection and they told us that staff treat them well and that they listen to them and act on what they say. One person said The staff are good, They look after us well. We examined a sample of the staff recruitment files and we found that satisfactory checks had been undertaken before staff had commenced employment at the home. Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: This included Criminal Records Bureau clearance checks and two written references. Staff told us that they receive supervision and the records that we looked at showed evidence of supervision at least six times per year. When we spoke with a staff member they told us that they receive a lot of training including safeguarding adults, fire safety, first-aid, manual handling and risk assessment. There is a sleep-in system at night, with on-call arrangements in the event that the person on duty requires further advice or assistance. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, safety and welfare of people is protected by the management systems in operation at the home. Evidence: In the AQAA self assessment the service told us about the satisfaction surveys that they undertake and about the meetings that they hold with the people living at the home. They confirmed that they keep health and safety records in accordance with their responsibilites. The home is managed by a person registered with the Commission. She has completed the Registered Managers Award and National Vocational Qualification Level 4. The staff and people living at the home that we spoke with during the inspection praised the manager for the way that she manages the home. The recording system for the management of personal monies held at the home on behalf of people living at the home was examined and was satisfactory. We also looked Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: at a sample of the maintenance and servicing documentation and this was also generally satisfactory. The manager expressed her concern that she had been unable to obtain documentary confirmation of the status of the fixed electrical wiring at the home, following extensive rewiring of the premises in 2006. She showed us evidence of the repeated efforts that she has made to obtain an electrical wiring inspection report. Despite her best efforts the housiing association has not yet provided this documentation to Mencap, the service provider. We had feedback from staff to confirm that they are receiving the necessary range of health and safety related training to enable them to support and protect the people living at the home. There are individual training records for each staff member that we were invited to examine, with details of all training undertaken. We looked at the quality assurance systems in place at the home. We were able to confirm at inspection that the mandatory monthly visits and reports by the registered provider are taking place. These regulatory visits (Regulation 26) are part of the quality monitoring processes, which act in the interests of people who use the service. The registered manager completes a range of audits of the service monthly called the Monthly Compliance Confirmation Report. The report covers key aspects of the service including incident reporting. There are periodic surveys of the views of family/carers and also a separate survey of the views of the people living at the home. There had been general analysis and summarising of the latest family/carer survey. There was no system in place to summarise the responses from people living at the home, in order to produce a published report in a format suitable for people using the service and for any prospective service users. We discussed with the manager at inspection about how the satisfaction survey process might be developed to provide feedback in a report format that could be included in the written information about the home that is available to current and prospective users of the service. 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 42 13 Regulation 13(4) (a)(c). There must be written documentation held at the home to confirm that the fixed electrical wiring has been inspected and is in satisfactory condition. This is to ensure that the health and safety of people living at the home is protected. 27/02/2009 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 19 Risk assessment for falls and nutritional screening should be undertaken for older persons living at the home, as per the National Minimum Standards - Care Homes for Older People (NMS 7 and 8). The homes safeguarding policy and procedure should be reviewed to ensure that it fully reflects the information in the local multi-agency referrals procedures and guidance document. The results of service user surveys should be summarised, published and made available to current and prospective Page 28 of 30 2 23 3 39 Care Homes for Adults (18-65 years) users of the service. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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. 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