Inspection on 17/12/08 for Cowley House

This inspection was carried out on 17th 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cowley House 28/12/07

Cowley House 23/07/06

Cowley House 11/10/05

Cowley House 18/04/05

Cowley House 23/08/04

Cowley House 07/06/04

Cowley House 07/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Cowley House Ray Park Road Maidenhead Berkshire SL6 8PZ     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: Jill Chapman     Date: 1 7 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 32 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 32 Information about the care home Name of care home: Address: Cowley House Ray Park Road Maidenhead Berkshire SL6 8PZ 01628638851 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Jacqueline Tracy Duggan Type of registration: Number of places registered: Care Management Group Ltd (trading as CMG Homes Ltd) care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 12 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 Cowley House is registered to provide accommodation and care for up to twelve service users, whose care needs, arise from learning disability. The range of care needs within the home is diverse and complex. Several service users have needs, which can challenge the service. The home is registered to accommodate service users over the age of eighteen years; many of the current service users are over the age of sixty-five. The current scale of charges as at December 2008 is between 493.36 and 12 Over 65 12 Care Homes for Adults (18-65 years) Page 4 of 32 Brief description of the care home 1399.19 pounds per week. There are additional charges for toiletries, chiropody, magazines, some activities and holidays. 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: 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 Commission has since April 2006 developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced Key Inspection. The inspector arrived at the service at 10 am and was in the service for 5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Care Homes for Adults (18-65 years) Page 6 of 32 The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgments about the standard of the service. The inspector spoke with the manager, deputy manager and two staff on duty. A tour of the premises was undertaken and records relating to care, staffing and health and safety were sampled. Feedback from service users was from questionnaires received prior to the inspection and discussion with some service users during the inspection visit. What the care home does well: What has improved since the last inspection? The home has reviewed its use of Care Management Groups referral and assessment process so that any new service user will be fully assessed prior to admission. Up to Care Homes for Adults (18-65 years) Page 8 of 32 date guidance has been sought from professionals involved in service users care to help staff manage risk and behaviours and meet service users needs. Improvements have been made in supporting service users to make decisions and choices and to make sure that they know how staff are implementing these. There has been an improvement in supporting the majority of service users to take part in activities and to have access to local leisure resources. A programme of redecoration and renewal is improving the environment for service users. Improved staff recruitment and training provides service users with better support to meet their needs. 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. 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 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 10 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Plans to update the Statement of Purpose and make the Service Users Guide more accessible will better inform service users. The majority of service users said they were given enough information about the home to help them decide to live there. The home has reviewed its use of Care Management Groups referral and assessment process so that any new service user will be fully assessed prior to admission. Up to date guidance has been sought from professionals involved in service users care to help staff manage risk and behaviours and meet service users needs. Potential service users have the opportunity to visit the home to help them decide if they want to live there. A Residents Agreement helps service users and their representative know what the placement has to offer and what service users responsibilities are. Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: There is a Statement of Purpose and Service Users Guide in place. The manager has updated the Statement of Purpose and has produced a user friendly Service Users Guide. Residents Induction checklists were seen on files sampled and show they are given necessary information about the home. Most service users confirmed they were asked to move into the home and received enough information to help them decide to live there. One said they were not consulted. Another service user said they did not think Cowley House was the the right place for them to live and staff are supporting them to negotiate with their care manager for a move to supported living. No new service users have been admitted since the last inspection but Care Management Group has a policy on referral and assessment in place. Care Programme Approach assessments from care managers are obtained and pre placement meetings and visits are arranged. A requirement from the previous inspection has been met. The new manager has obtained relevant paperwork from previous admissions from Head Office to put on service users files. The new manager and key workers have been liaising with relevant professionals to improve communication with service users and learn more about managing individual risk, physical and mental health needs. Behavioural programmes and guidelines are being implemented and have been put on file to demonstrate that the home is meeting service users needs. Residents agreements were seen on three service users files sampled. Care Homes for Adults (18-65 years) Page 12 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive care and support to meet their assessed needs as outlined in their care plan. They are supported to take responsible risks and to be as independent as possible. The review of some risk assessments will make sure that identified risks are properly documented. Improvements have been made in supporting service users to make decisions and choices and to make sure that they know how staff are implementing these. Evidence: Three service users files were sampled and care plans and risk assessments were seen on each one. Care plans and guidelines sampled were up to date and these are reviewed at monthly key worker meetings. Care plans seen covered a variety of diverse needs including cultural, spiritual, sexual and relationship and daily living skills. Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: Risk assessments sampled for one service user showed that a serious risk had not been fully documented. Bathing risk assessments for three service users needed more information. The manager agreed to review and update these. Service users are encouraged to make decisions and choices and the manager is promoting improved communication and use of objects of reference to help non verbal service users make choices. Staff have attended a 3 day course in preventing and managing challenging behaviour and an emergency on call system is now in place. It was seen that the format of service users meetings has changed to show what progress has been made in meeting service users requests about home and community activities. An advocacy service has been contacted to support service users in making decisions and choices. Care Homes for Adults (18-65 years) Page 14 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. There has been an improvement in supporting the majority of service users to take part in activities and to have access to local leisure resources. Some service users with higher care needs have limited opportunities due to insufficient staff to cover their activity needs. Staff support service users to keep in touch with family and friends. Service users can help choose and prepare their meals and staff support them to eat healthily. Evidence: Service users surveyed confirmed that they can choose what to do each day. One said I can decide what time I get up and go to bed. An activity sheet and daily diaries show Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: that activities are planned and carried out. Service users have enjoyed day trips out including a river boat trip, visits to local pantomime and cinema and meals out in a restaurant. On the inspection day service users and staff had a lunchtime Christmas meal out. Daily routines are flexible to meet the varying ages and needs of the service users. Two attend day services, one has a weekly music therapy session, another has guitar lessons and aromatherapy sessions are available for those who wish to join in. Some go to the Monday club. Service users from Cowley Cottage (another home on site) sometimes join in birthday celebrations and activities. Activities have improved in house, service users are supported to access a local craft shop and one showed their art and craft equipment. A service user was making Christmas decorations for the lounge and dining room. One service user likes knitting and others like listening to music. A previous requirement to make arrangements for service users to take part in valued and fulfilling activities has been met for the majority of service users. There has been a general improvement in activities made available for service users, however those who have two to one staffing needs still miss out on opportunities because of insufficient staffing levels. This issue was identified in staff surveys and the manager has been trying to address this issue by recruiting new staff and re negotiating the contracts of these service users. Care Management Group provides funds towards the cost of service users holidays. Some service users have been away to Butlins at Bognor and two are planning a holiday in Spain. In discussion with the manager there was evidence that potential risks are assessed when planning holidays and the manager confirmed she is going to develop risk assessments to support these. Service users and staff described how service users are supported to keep in touch with family and friends. This includes helping with the transport to visit relatives over the Christmas period. The manager said that Care Management Group have recently supplied the home with a computer and that e mail has made it easier to communicate with relatives. Service users are involved in the choice of meals provided and one said they like to help with the shopping and meal preparation. Another service user described the various main meals he cooks. There is a system for the daily checking of fridge and freezer temperatures and records are kept of these temperatures. Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: Care Homes for Adults (18-65 years) Page 17 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. Staff support service users to maintain their personal care and hygiene in the way they prefer and uphold their privacy and dignity. Relevant professional guidance has been obtained in the management of behaviours and speech therapy assessments have been obtained to help staff understand service users communication needs. A robust medication procedure helps keep service users safe and well. Evidence: A previous requirement that service users must be provided with flexible personal support to maximize their privacy, dignity, independence and control over their lives has been met. Three service users files were sampled and show that there are guidelines in place to support service users with their personal care. The home has sought support from a Behavioural Nurse Specialist about supporting one service user to maintain good personal hygiene. The AQAA (Annual Quality Assurance Assessment) states that personal care is provided in privacy and to support dignity. During the inspection it was seen that staff supported one service user in private with their morning routine and it was heard that they carried out a consistent and patient Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: approach in responding to challenging behaviour. A previous requirement that a system for contacting staff within the home in an emergency must be put in place has been carried out. A mobile alarm call system has been purchased for staff to summon extra help in supporting service users if needed. There was good evidence that service users health care needs are met. Health care plans are in place and there are plans to review these more frequently. Records are kept of appointments with the GP and other health professionals involved in service users care. The manager said there is good support from professionals in the local Community Team for People with Learning Disabilities. The manager has focused on improving communication with service users. Speech therapy assessments for individual service users have been completed, objects of reference are used and new staff whose first language is English have been employed. There is an appropriate system for the storage and administration of medication. The administration procedure was observed during the inspection and was carried out correctly. Care Homes for Adults (18-65 years) Page 19 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users know who to talk to if they have a concern and complaints are investigated and dealt with. Staff are trained to know how to protect service users and to recognise potential abuse. Evidence: A previous requirement that all complaints received must be recorded in line with the homes complaints procedure has been met. The Complaints procedure is displayed in the office and complaints log book is held. There is guidance on the log book to show staff how to complete the record. The record was seen and some more information is needed to fully show the outcome of some complaints. The Commission has not received any information about complaints made about the service. The AQAA shows that the home has received and dealt with 3 complaints since the last inspection. Service users surveyed said they knew who to talk to if they had a concern. The Commission has not received any information about any safeguarding issues that relate to this home and the AQAA (Annual Quality Assurance Assessment) shows that the home have not needed to make any safeguarding refferrals. Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: A requirement that all staff must receive training on safeguarding adults has been met. The AQAA (Annual Quality Assurance Assessment) shows that all staff have received POVA (Protection of Vulnerable Adults) training. Staff have also received training on how to deal safely with challenging behaviour and observation and incident records are kept. There is a system in place for the safekeeping of service users monies and receipts and expenditure records are kept. This was sampled during the inspection and records of monies seen were accurate. Care Homes for Adults (18-65 years) Page 21 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from a home that meets their needs and is kept clean, hygienic and well maintained. A programme of redecoration and renewal is improving the environment for service users. A broken bath chair has meant that service users have not been able to choose between a bath or shower for over six months. Evidence: A tour of the premises was carried out and shows that there is a programme of redecoration and refurbishment underway. The lounge and dining room had just been painted and a service user was making and hanging Christmas decorations. It was seen that some communal carpets are worn and badly stained and the manager confirmed that plans are in place to replace these. There is a new range style cooker and a computer for the staff office. Some service users showed the inspector their bedrooms, they were well furnished and reflected the individuals personality. The home is accessible for wheelchairs and there are adaptations and specialist equipment in place. It was seen that the the bath chair in an upstairs bathroom is broken and has been out of action for over six months. The manager said that Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: arrangements have now been made to have this rectified. It will be a requirement from this report that this is carried out to make sure that service users have the choice of either a bath or shower. There is a separate laundry that service users can use to do their own personal laundry, the washing machine has a sluice programme and there are facilities for the disposal of clinical waste. Staff have received training in infection control. Service users surveyed said the home is kept clean and hygienic. Care Homes for Adults (18-65 years) Page 23 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. Improved staff recruitment and training provides service users with better support to meet their needs. Staff deployment does not meet all of service users current activity and community access needs because some service users need increased staff support due to the aging process or challenging behaviour. Evidence: There were four requirements relating to staffing from the last inspection. Requirements to make sure that staff have training to meet the needs of service users and to make sure that staff have training in moving and handling, infection control and food hygiene have been carried out. The training plan and AQAA (Annual Quality Assurance Assessment) shows that the new manager has booked various training courses to update and train staff to meet service users needs. This includes challenging behaviour, manual handling, infection control, food hygiene, fire safety, dementia, epilepsy and autism. Staff spoken with confirmed their recent training. Staff at Cowley House come from diverse cultural backgrounds and the manager has Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: identified that employing more staff whose first language is english would balance the team better and help communication with service users. Two new british staff have recently been employed although one has subsequently left. The manager said that they will continue to try and recruit more staff whose first language is English. Since last inspection four staff have been put forward for NVQ 2, three for NVQ 3 and the deputy manager for NVQ 4. A requirement to make sure that the recruitment procedure is more robust to protect service users from possible harm has been met. The recruitment files of two staff were sampled and show that the procedure was followed. This included carrying out POVA (Protection of Vulnerable Adults) list and CRB (Criminal Records Bureau) checks and seeking two references prior to employment. Staff spoken with confirmed their recruitment and induction process. There is a system of regular supervision in place and this was evidenced by a supervision plan and from speaking to staff. The manager is currently aiming to supervise staff monthly. Service user surveys show that staff treat service users well and listen to what they say. Observation of practice during the inspection showed that staff interact well with service users and are consistent in their approach. A requirement to ensure that at all times there are suitably qualified, competent and experienced staff on duty in sufficient numbers as are appropriate for the health and welfare of the service users has not been fully met. There is an ongoing problem in recruitment and retention of staff at Cowley House. Both verbal and staff survey information shows the level of pay for support workers is considered to be low and that it affects the recruitment and retention of staff. The manager said that Care Management Group are currently reviewing this situation. There was verbal and staff survey evidence that current staff deployment is not adequate. Some service users have increased personal care needs due to the aging process and one service user has challenging behaviour that requires 2-1 staffing for personal care and for accessing the community. Although staff are meeting personal care needs they are extremely stretched and service users who need two to one staffing are having very limited access to the community. Staff also cook the meals and carry out domestic tasks. The manager is currently reviewing cleaning duties to see if a domestic staff should be employed. Care Homes for Adults (18-65 years) Page 25 of 32 Evidence: In looking at staff rotas for the same period in 2007 staff levels on daytime shifts were one more carer per shift than they are now. The manager is aware that more staff are needed on shift and Care Management Group have told the Commission that they are planning to review service users contracts with the purchasers over the next 3-6 months. The registered persons must make sure that the home has a system in place to ensure that at all times there are enough staff on duty to meet all of the assessed needs of all of the service users including the opportunity to access the community, to pursue interests and activities and to support people who present challenging behaviour. Care Homes for Adults (18-65 years) Page 26 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a new qualified and experienced manager in post and the management of the home and the operating systems have improved. Service users, staff and relatives views are taken into account in developing the service. The views of other stakeholders would further develop the way the home gets feedback. A review of the policies and procedures would make sure that the home has up to date copies. Health and safety systems are maintained up to date for the protection of service users and staff. Evidence: A new manager has been in post since June 30th 2008. The manager is experienced Care Homes for Adults (18-65 years) Page 27 of 32 Evidence: and has completed the Registered Managers Award and NVQ level 4 in September 2008. The manager is in the process of completing an application to be registered. Since being in post the manager has begun a continuous improvement plan for the home. It was found that care and staff systems are well organised and up to date. The homes office now has a computer and the manager said that this has been an essential management tool to help update systems and to communicate with other professionals. The manager provided an AQAA (Annual Quality Assurance Assessment) to the Commission prior to the inspection. It was well filled in and gave us the information we needed. From discussions with staff and from staff surveys it was clear that despite staff shortages staff morale has improved and that the manager is accessible and supportive. One staff said that staff are treated equally and that this has improved how staff work as a team. Staff have clearly delegated tasks and the manager said that staff are more confident in carrying out their role. The home has a number of ways it seeks feedback from service users and others about the service. Regular service users meetings are held and progress in relation to service users requests is documented. Service users confirmed that suggested outings and activities have taken place. User friendly questionnaires are sent to service users and questionnaires are also sent to staff and relatives. A monthly internal audit is carried out and this informs the monthly Regulation 26 visits. These all help inform a Quality Assurance Action Plan to help develop the service. It is recommended that the views of other stakeholders, e.g. GPs, care managers and health professionals, are sought to help inform the Quality Assurance Process. The AQAA shows that there are a range of corporate policies and procedures in place but some do not appear to have been updated since 2006. It is recommended that the manager review these to make sure that the home has the most recent copies. The AQAA (Annual Quality Assurance Assessment) shows that equipment is regularly maintained and serviced. A health and safety audit is carried out monthly. Health and safety records were sampled and were up to date. Care Homes for Adults (18-65 years) Page 28 of 32 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 29 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 27 23 Repair or replace the bath chair, to give service users a choice between a shower or bath. 28/02/2009 2 33 18 The registered persons must 24/12/2009 make sure that the home has a system in place to ensure that at all times there are enough staff on duty to meet the assessed needs of all of the service users, To include the opportunity to access the community, to pursue interests and activities and to support people who present challenging behaviour. 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 30 of 32 1 39 That the views of other stakeholders are sought to help inform the Quality Assurance Process. That the manager review the the policies and procedures to make sure that the home has the most recent copies. 2 40 Care Homes for Adults (18-65 years) Page 31 of 32 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). 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. 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