Inspection on 11/10/08 for Copse Lea

This inspection was carried out on 11th October 2008.

CSCI found this care home to be providing an Adequate 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

Copse Lea 18/10/07

Copse Lea 06/03/07

Copse Lea 04/05/06

Copse Lea 20/12/05

Copse Lea 11/08/05

Copse Lea 17/11/04

Copse Lea 26/05/04

Copse Lea 18/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Copse Lea Copse Lea Tringham Close Ottershaw Surrey KT16 0NF     The quality rating for this care home is:   one star adequate 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: Robert Pettiford     Date: 1 1 1 0 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: Copse Lea Tringham Close Copse Lea Ottershaw Surrey KT16 0NF 01932873802 Telephone number: Fax number: Email address: Provider web address: penny.lamb@surreypct.nhs.uk Name of registered provider(s): Name of registered manager (if applicable): Welmede Housing Association Ltd The registered provider is responsible for running the service care home 6 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 6. The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - LD Date of last inspection Brief description of the care home Copse Lea is a residential home for up to 6 adults who have learning disabilities. Welmede Housing Association manages the service. The service is a detached property and the facilities and accommodation are set on two floors. There is no mechanical means to access the upper floor and none is required for the existing residents. All residents have a single bedroom and access to a separate lounge, dining room and kitchen. There is a large garden to the rear of the house and other garden areas to the Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 6 Brief description of the care home front and side. The home is situated in a residential cul-de-sac in Ottershaw, which has a range of local facilities, including shops, post office, pubs and public transport. Fees not known at time of inspection. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The inspection took place on 11th October 2008. We agreed and explained the inspection process with the deputy manager present at the time of the inspection and the supervising manager who joined later. The focus of the inspection was to assess Copse Lea in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, preCare Homes for Adults (18-65 years) Page 6 of 30 inspection information such as the previous report and discussion and correspondence with the registered provider/manager was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home has completed an annual quality assurance assessment questionnaire (AQAA), which was received on time. This provided us with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the CSCI to be able to make an informed decision about outcome areas. Further information can be found on the CSCI website with regards to information on KLORAs and AQAAs. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, rotas, training records and recruitment records. In addition an environmental tour took place. We identified several residents for case tracking. In addition the inspector had the opportunity to speak with several of the residents and a number of staff. Additional evidence was gained to inform judgements following the observation of many of the residents and their interactions with staff. 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 set out on page 4. Care Homes for Adults (18-65 years) Page 8 of 30 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 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be confident that their needs will be properly assessed prior to moving to the home. Prospective residents also have the benefit of a trial period at the home. Evidence: Records held showed that residents have an assessment, which identifies their individual needs prior to or on admission to the home. This is then reflected into the care plans and these are developed in agreement with the individual where possible. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the needs of the individual. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. The AQAA also confirmed detailed information with regard to ensuring that the home can meet the needs of residents. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: The assessment process recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The home evidenced in its AQAA that it reviews it equalities and diversity policy and ensures that all of the information and policies relating to residents are inclusive to all members of the community. The AQAA stated that all staff recieve Equality and Diversity training. Prospective Residents have the benefit of a trial period at Copse Lea to assess whether the home can or cannot meet their needs. Care Homes for Adults (18-65 years) Page 12 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. Residents benefit from having clear individual plans that are comprehensive, identify their needs and are specific to the individual. Care plans showed that residents are enabled to make decisions and choices and enabled to take responsible risks through a thorough risk assessment process. Evidence: The key principles of the home for delivering a quality service are based on the belief that residents should be able to take control of their lives. The staff of the home are strongly committed to supporting all residents including those with limited communication or learning disabilities to make informed decisions, understand the range of options which are available to them and have the right to take responsible risks. Evidence of this was gathered through taking to the residents, staff, and the deputy manager. The home and its staff are committed to supporting the residents in accordance with Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: their needs and goals. This was evidenced through the care plans, which detailed the areas of support that the resident needed and how this support is provided by the staff. There were clear guidelines in respect to routines and supporting the residents with their needs. The deputy manager confirmed that these are reviewed with health care professionals, relatives and residents where possible on a regular basis. The inspector viewed a sample of two care plans, which showed short and long term goals. The plan focuses on current need. The plans of care follow the principles of person centred planning. Staff support and encourage the individual to be fully involved. Residents rights to make decisions are respected and the care plans reflected their ability to make an informed judgement where possible. Care plans included information concerning the preferred lifestyle and choices. We visited the home at 9:45AM. During the inspection the Inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process where possible. A relaxed atmosphere was noted with the residents interacting with staff and eating a cooked breakfast. We found that the home has a genuine commitment to supporting residents to contribute in the day to day running of the home. Staff were responsive and receptive to the residents input. Examples of such included choosing activities and planning of the day ahead. There were guidelines in respect to routines and behaviour. The member of staff confirmed that these are reviewed with the residents on a regular basis and the families are supported to be involved. Daily records were not wholly comprentaneous in that they had gaps and full names of staff were not seen. It was strongly recommended that the home follow the Nursing and Midwifery Council guidance: Guidelines for records and record keeping. Residents rights to make decisions are respected and the care plans reflected their ability to make an informed judgement where possible. One resident spoke of his part time job for the local council and his love of aeroplanes. Care plans include risk assessments. Management of risk takes into account the specialist needs and age of people who use the service, balanced with their aspirations for independence, choice and normal living. Where there are limitations on choice or facilities, it is in the persons best interest. The Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: resident understands and agrees the limitations where possible. Any limitations are fully documented but are overdue for review. Care Homes for Adults (18-65 years) Page 15 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. Residents can be confident that they are offered a range of opportunities for personal development and to learn new skills and feel part of the wider community. Residents engage in a good level of activities which are appropriate to their needs and capabilities.Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered at the home. Evidence: Residents are enabled to participate and contribute to meeting their own self care needs and day to day chores around the house as their capacity allows. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: Discussion with staff and residents confirmed that the level of activities were of a good level and that they enjoyed a good level of stimulation through leisure and recreational activities both inside and outside the home. We joined residents at 9:45am while they were eating their breakfast. The inspector had the opportunity to speak to several of the residents later in the day who expressed their opinion of the home and the activities they participated in and enjoyed. Other residents were observed participating and interacting with staff. Residents have been enabled to and encouraged to participate in hobbies and activities which they had an interest in, such as maintaining and building on personal collections and specific recreational activities. One resident spoke of his love for aeroplanes and that he enjoyed doing a part time job with the local council with full support from staff. Another spoke of the things she liked doing. The service actively encourages and provides varied opportunities for Residents to develop and maintain social, emotional, communication and independent living skills at Copse Lea. The staff have a good ethos and focuses on involving Residents in all areas of their life. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. Examples of such included provision for relatives and friends to visit the home and support being provided to enable services users to visit relatives or friends outside the home. Residents were consulted with regard to whom they saw and when and were under no compulsion to accept visitors should they not wish to do so. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the residents activities and schedules. Residents are able to choose where to eat, and also have facility to make drinks, meals and snacks for themselves and others with staff support should they wish. Residents on evidence seen have had been involved in planning and choosing what to eat where possible. One service user explained the menus how his choice and preferences influenced the menu. Care Homes for Adults (18-65 years) Page 17 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. Residents feel supported by the level of help given and that their healthcare needs are addressed.The service user can feel confident that their wellbeing will be protected by the homes policy and procedures with regard to the handling and administration of medication. Evidence: The care plans fully documented the personal support required for individual Residents within Copse Lea. They reflected their choices and preferences and staff were observed offering guidance where needed. Times of getting up / going to bed, having baths, eating meals and other activities are flexible to allow for different Residents daily routines. The inspector observed excellent interaction between staff and Residents. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the Residents. It is recognised that the delivery of personal care is highly individual and must be flexible, consistent and reliable. Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to changing needs of Residents. Where possible Residents Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: are supported and helped to be independent and responsible for their own personal hygiene and personal care. The care plans fully documented all physical and emotional healthcare needs and where able residents filled in or were supported to fill in appropriate forms. Within the care plans records of health care provided by G.P, chiropodist, dentist, and opticians were evident. Residents physical and emotional health is monitored on a daily basis. Through their daily records and these correspond with records held in the care plans. This system ensures that all Residents receive continuity of care and supports potential complications and problems at an early stage. It is evident through records that the emotional health support is of a high priority to this home and the staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. We viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of PRN/s Required Medication within the home. The deputy manager confirmed that all staff who dispense medication have received the appropriate training. The inspection of the homes system for storage and the administration of medication brought no concerns. The MAR sheets (drug record sheets) were being completed properly. Doses were not missed and the MAR sheet were able to indicate a reason for missing the dose. The medication file / MAR sheets did have a signature list to evidence who gave the medication signed for on the MAR sheet. Care Homes for Adults (18-65 years) Page 19 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. Residents and their relatives know that their concerns and complaints are taken seriously. Residents can feel confident that they are protected from the risks of abuse. Evidence: A copy of Copse Lea complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. The complaints procedure is highly visible within the service and is more readily available in different formats. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. Two complaints have been recieved from information contained within the AQAA. Syastems are in place to ensure that these are dealt with appropriately. The homes Policy for the Protection of Residents and staff Whistle blowing procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided for staff. The home promotes an open culture where Residents feel safe and supported to share Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: any concerns in relation to their protection and safety. Policies and procedures regarding protection are in place. Whist staff recruitment files were not inspected on this occasion the manager stated that Criminal Record Bureau Checks (CRB) had been obtained for all staff . Care Homes for Adults (18-65 years) Page 21 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. Residents benefit from living in a good well maintained environment which provides a homely warm atmosphere with safe access to comfortable indoor and outdoor communal areas. However the garden could be improved to minimise risks. Evidence: We observed that the home is set in well maintained gardens. A greenhouse was seen however with broken windows. This could be a health and safety risk for both residents and staff. The deputy manager was requested to risk assess it and seek options to minimise risk. It was apparent that the individual and collective needs are being met in a comfortable environment. The standard of internal decoration and fixtures and fittings are well maintained and of a good quality. The home benefits from a wide selection of communal areas thus affording residents space should they so wish desire. The AQAA stated that new adapted bath has been fitted to ensure safety and to meet special needs for residents on the ground floor. New bathroom suite has been fitted on the first floor for the more able residents. New flooring fitted in both bathrooms. The home has also been fitted with a new kitchen. All bedrooms has self closing Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: mechanism. An extra radiator has been fitted in the corridor. Patio slabs has been levelled, regrouted and pressure washed. The above improvements to the home address the requirments outstanding from the last inspection. The premises are kept exceptionally clean, hygienic throughout and systems are in place to control the spread of infection. Care Homes for Adults (18-65 years) Page 23 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents care, social and emotional needs are promoted by the employment of caring in such numbers to support their needs who put the interests of the residents first. Residents can not be wholly confident that the home is managed by sufficiently competent and experienced persons. The standard relating to staff recruitment procedures was not inspected. Evidence: From discussions with the deputy manager, observations and reviewing the staff rotas more than sufficient staff were on duty at the time of inspection to meet the residents needs. Staff are receptive to residents needs and work together as a team. The staff training records indicated planned and undertaken training. The deputy manager evidenced that individual and group staff training needs had been identified. Core courses are undertaken by staff to maintain current qualifications and for protection of residents. The provider had advertised for a manager and successfully employed one, but due to Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: various difficulties was unable to start work. The provider is actively looking for a replacement and is aware that this is a priority. However the home continues to not have a manager and is being managed by a deputy manager and overseen by another manager from one of the providers homes. The shortfall in the provision of a manager who has the experience and qualifications could put the residents at risk. The supervising manager confirmed that the home has a development programme for all new staff, which meets Sector Skills Councils workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users, and that all members of staff receive induction training to specification. Evidence was not readably available at time of inspection. The service has a recruitment procedure but the inspector was unable to inspect as the records were not available at time of inspection. Care Homes for Adults (18-65 years) Page 25 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are currently being met however they can not be confident that the home is managed appropriately due the lack of a manager and that the quality assurance of the service has the potential to be monitored inconsistently. Evidence of health and safety safety checks were not fully inspected on this occasion. Evidence however was in place that the home has a system to ensure that fire doors are kept open. This showed that a previous requirement re fire safety had been met. Evidence: The deputy manager is actively involved in the day-to-day management of the home and works with staff and residents. Outcomes for the quality of care are good. Residents expressed a great deal of satisfaction of the care provided and the staff are very supported of the deputy manager and have a positive ethos. The home does not however currently have a manager and the management of the home as previously written is overseen by another manager from one of the providers other homes. Whilst it is accepted that the deputy manager has been instrumental in ensuring that the care Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: needs of the residents are meet she does not have the experience or management competencies to ensure that the home is managed properly. The deputy manager is to be commended on her efforts to maintain standards of care and that it is run to the best of her ability. Shortfall in the provision of a manager who has the experience and qualifications could however put the residents at risk and impact on other areas of the home. The provider had advertised for a manager as previously stated and successfully employed one, but due to various difficulties was unable to start work. The provider is actively looking for a replacement. There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. Quality assurance was discussed and the views and opinions of many of the residents and stakeholders sought. The residents spoken with confirmed a great deal of satisfaction living within the home and felt confident that their views and opinions were valued by both staff and management. Surveys have not been carried out by the home to contribute to the quality assurance process. The home operates a key worker system to identify an individual staff member to directly to work with a service user on a one to one basis. An appointed person of the registered provider of the home does regularly visit the home and complete what is known as a Regulation 26 visit. This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. However the quality of such Regulation 26 visits viewed could be improved and made more comprehensive and consistent. This role is not carried by one person. Presently upwards of six different people carry out these audits. It is the view of the inspector that this did not contribute to them being consistent. The provider was reccommended to appoint one person to carry out this role and survey stakeholders for their views. No requirment has been made at this time. . Evidence of health and safety safety checks were not fully inspected on this occasion. Evidence however was in place that the home has a system to ensure that fire doors are kept open. This showed that a previous requirment re fire safety had been met. Care Homes for Adults (18-65 years) Page 27 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 28 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 37 8 The registered provider shall 11/01/2009 appoint a suitably qualified and experienced manager to manage the home To ensure that residents needs are met and their health and safety is protected 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 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. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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