Inspection on 26/02/09 for Greengate House

This inspection was carried out on 26th February 2009.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Greengate House 06/03/07

Greengate House 29/03/06

Greengate House 19/08/05

Greengate House 09/11/04

Greengate House 27/05/04

Greengate House 15/03/04

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

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Greengate House Samuel Street Nutgrove St Helens Merseyside WA9 5LT     The quality rating for this care home is:   three star excellent 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: Janet Marshall     Date: 2 6 0 2 2 0 0 9 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. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) 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.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Greengate House Samuel Street Nutgrove St Helens Merseyside WA9 5LT 01744850029 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): carole.edwards@makingspace.co.uk Making Space Name of registered manager (if applicable) Mrs Carole-Ann Edwards Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Service Users to Include up to 12 (MD) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection Brief description of the care home Greengate House is a two storey purpose built home located in the St Helens area of Liverpool. The home accommodates up to 12 residents under the category of mental disorder. It is close to local amenities and public transport links. The building is made up of three self contained units each having four bedrooms, a lounge, bathroom and separate toilet. The home also has a number of other communal areas including a large lounge, dining room and a conservatory with views into a well maintained and attractive back garden. The home is owned managed by Making Space, a registered Care Homes for Adults (18-65 years) Page 4 of 29 care home 12 Over 65 0 12 Brief description of the care home charity that offers support to people who are suffering with schizophrenia or other mental illnesses. The homes registered manager is Carol Edwards. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The Quality rating for this service is 3 star. This means the people living at the home experience excellent outcomes. This was a key inspection. We consider 22 out of the 43 National Minimum Standards for this type of service, Care homes for Adults (18-65) as the key standards, which have to be inspected during a key inspection. The key standards are highlighted in bold in the different outcome sections of this report. A key inspection is a planned inspection, the report is put together using information gathered in a number of different ways, which helps us decide the overall rating of the service. We keep all information we receive about the home in a file, we looked at all the information we have received since the last inspection. We sent out a form to the home Care Homes for Adults (18-65 years) Page 6 of 29 called an Annual Quality Assurance Assessment (AQAA). The AQAA has to be filled in and returned to us by a set date usually before the site visit takes place. The AQAA was filled in by the manager and returned to us on time and provided us with all the information we asked for about the home. We carried out an unannounced visit to the home, this is when we visit the home with out any body knowing. The manager was not on duty at the time of the site visit but the deputy manager and other staff that were on duty helped with the inspection. Discussions took place with the staff and a number of residents that live at the home. Also during the site visit a selection of records and certificates, which have to be kept in the home by law were looked at and checked to make sure they were up to date and accurate. Some residents were case tracked. This is a process we use to find out whether residents are receiving good quality care that meets their individual needs. It is done by talking to people, looking at results of surveys and reading the records of a sample of people that live at the home to give us a good idea of what it is like for them. Before the site visit took place we sent out Have Your Say surveys to people asking them about what it is like to live and work there, three staff surveys were returned at the time of writing the report, responses and comments included in them have been used in parts of this report. 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. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care need requirements are fully assessed before a decision is made about them moving into the home to make sure it is the right place for them to live. Evidence: The AQAA told us that people are only admitted to the home with a full needs assessment, which takes account of their needs and desired outcomes. Assessment and admission procedures were in place at the home and were clearly described by the deputy manager who was on duty at the time of the inspection visit. A number of new residents have been admitted to the home since the last key inspection. Care records for two new residents were looked at in detail. They included copies of full need assessments carried out by either the manager or a deputy manager of the home. The homes pre-admission assessments were detailed and comprehensive covering care need requirements such as communication, finances, mental and physical health care, personal care and social care. Assessments carried out by other health and social care professionals were also part of Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: the new residents care records and used to make a decision about the suitability of the placement. Case tracking showed that each persons care plans were developed from information taken from their pre-admission need assessments. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have an up to date care plan providing staff with information about how they want and need to be supported in a way that ensures their independence and safety. Evidence: As part of the case tracking process care plans for a number of residents were looked at in detail, this included looking at a new residents care plan. The care plans were very well organised and easy to read. As previously stated case tracking showed that Information taken from assessments had been used to put together each persons care plans. Care plans were person centred with evidence to show that they were put together, regularly reviewed and updated with the full involvement of the resident and other people in their lives who are important to them. A person centred care plan makes sure that people are supported in a way that gives them more choice and control over their own lives. During the site visit staff spoken with showed a real good understanding about care plans, how to use them and the importance of them. One member of staff commented, Care plans provide us with important information about Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: residents so that we can support them in the right way. Have Your Say surveys for staff that were completed and returned to us showed that they are always given up to date information about the needs of the residents. Residents spoken with confirmed they had a care plan, which they have seen and helped put together. One resident said, Yes I know about my care plan, I know were it is kept and what is in it. I know I can read it anytime I want. Residents are encouraged and supported to make every day decisions and choices about all aspects of their lives, for example what time they get up and go to bed, how they spend their day, what clothes they wear and the food they eat. One resident said, I choose all my own clothes and what I wear each day, Yes I choose what time I go to bed and when I get up of a morning. Another resident said I do what I want, If I feel like it I stay up late at night and watch TV and videos. Care plans included information about the persons level of ability to make choices and decisions and for those that need assistance details of the support they need was well recorded. Choices and decisions, which are made by others and the reasons why were also recorded as part of the persons care plan and agreed by the appropriate people. Residents have keys to their own rooms and a facility to lock away any personal items they have. Residents are encouraged to take responsible risks as part of an independent lifestyle. When a potential risk is identified a risk assessment is carried out to enable the person to carry out a task or activity safely as independently as possible. Care plans which were looked at included risk assessments. They were very detailed and provided staff with clear information about the safest way to support a person in a situation, which is likely to pose a risk to them. Risk assessments viewed showed that they had been regularly reviewed and were necessary updated. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents enjoy active and healthy lifestyles. Evidence: The AQAA told us that residents are supported and encouraged to live independently. This includes encouraging and supporting their educational, training and social needs. It also told us that residents have taken up further education, one resident is involved in voluntary work and that social inclusion team work shops involving employment voluntary advisors take place every 6 weeks as another way of supporting residents involvement in education and occupation. The AQAA told us that residents are part of the local community. This is encouraged by giving them every opportunity to access local services and facilities. Residents spoken with said they get out and about a lot. Places they said they had visited recently included, pubs, shops, health care centres, libraries, churches and colleges. Residents also said they use public transport including Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: buses and trains. Care plans, which were looked at during the site visit included information about residents preferred pass times, hobbies and interests, information about important relationships and significant events in their lives was also recorded. Daily records, which were looked at as part of the case tracking process showed that residents are given appropriate lifestyle opportunities both in and outside the home. Residents at the home are offered to take part in a rehabilitation programme. Programmes are devised around each persons individual needs and focus on developing their independence and confidence with a view of them moving on in the future. A room in one of the units at the home has been converted into a fully equipped kitchen where residents are supported by specialist staff to learn and develop daily living skills such as cooking and cleaning. Other living skills, which were part of residents rehabilitation programmes included, managing finances, shopping, social integration, training and employment. Records looked at included regular reviews and progress reports of residents rehabilitation and personal development plans. The AQAA told us that residents are treated well, which included ensuring their privacy, dignity, rights and equality. During the site visit staff were seen treating residents well and they were patient and sensitive towards their needs. They spoke to them in a polite and gentle way and were seen knocking on doors and being invited in before entering residents bedrooms. Staff spoken with gave good examples of how they ensure residents privacy and dignity including: I always give residents choices. I encourage them to do as much as they can for themselves. If a resident wants to talk to me about a personal matter I make sure it is done in private. I knock on bedroom and bathroom doors before entering. When helping a resident with personal care I always make sure the room is warm, they have their own toiletries and the door is locked. Residents spoken with were asked about how staff treat them, their comments included: The staff are very kind and helpful. All the staff treat me very well they never shout. The staff always knock on my door before coming in my room. Residents generally sit together to eat their set meals in the main dining room but if they choose can eat in their bedrooms or other parts of the home. Lunch time was spent sitting with residents in the main dining room. Tables were attractively laid and hot and cold drinks were offered to residents before, during and after their meal. Each person was individually served with their choice of meal. Meal time was relaxed and unrushed and residents were offered extra portions of food. Residents spoken with were all complimentary about the choice and quality of food at the home. Comments made by them included: The food is lovely, we get enough and the choices are good. Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: The food is really good and we always get a choice. There is a good choice of food and always plenty to eat, we can have a cup of tea and a snack when we want. Menus, which were viewed were varied, healthy and well balanced. Residents spoken with, said they were involved in putting together the menus. Some residents are on a healthy eating plan or have other special dietary needs. Information about residents dietary needs, likes and dislikes with regards to food was recorded in their individual care plan. The kitchen, which was viewed was clean and well organised there was a good stock of fresh, frozen and dried foods. The cook who was spoken with was very knowledgeable about each of the residents dietary needs and their food preferences. A member of staff explained that residents involved in rehabilitation programmes go out to local supermarkets to buy the food for the meals they plan to prepare and cook. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents personal and healthcare needs are well supported and understood making sure they stay well. Evidence: Residents care plans included detailed information about their personal and health care needs and how staff need to support them. The AQAA told us that personal support is carried out in a dignified way and in private. It also told us that personal care is carried out in a way that the person prefers. During the site visit staff were seen helping residents with personal support. It was done in private and they did not rush residents. Records looked at showed residents attend regular healthcare appointments and their health is well monitored to make sure they stay well. When required residents have visited their doctors, dentists, chiropodists and attended hospital appointments. Residents with specialist health care needs receive the right support by staff who have received training and regular advice about how to manage their conditions. Staff spoken with were knowledgeable about residents individual personal and healthcare needs and they were confident about dealing with them. Staff were able to describe what they would do if a resident suddenly became ill. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: The AQAA told us available at the home are up to date policies and procedures about medication. Medication which was checked during the site visit was stored and recorded in the correct way. Staff spoken with during the site visit said they have taken part in training about medication. Residents care plans included information about their medication such as why they are given and the possible side effects. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Procedures, which were in place at the home ensure that residents are protected from abuse, harm or neglect. Evidence: Since the last inspection no body has made a complaint to us about the home and the AQAA told us that no complaints have been made directly to the home. The AQAA told us there are policies and procedures at the home to help people make a complaint if they need to, these were looked at during the site visit. As well as a complaints procedure there was also easy to follow guidelines for people to follow. All the documents, which were on display at the home were in an easy read format and step by step instructions. Residents spoken with during the site visit said they have information about how to complain and would definitely make a complaint if they needed to. Staff spoken with also knew about the homes complaints procedures they explained correctly what to do if they had a complaint or if a resident made a complaint to them. The AQAA told us that there are adult protection procedures at the home including a copy of St Helens Local Authorities procedures. Staff spoken with knew about these and said they have read them. Staff also said they have attended Protection of Vulnerable Adult (POVA) training and were confident about what they would do when asked about reporting incidents of abuse. Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: Available at the home were strict procedures and processes, which staff have to follow when dealing with residents money. Money and records which were checked were in good order. Residents had bank accounts in their own name and there were processes in place to enable them to safely access their own money when they want. Care Homes for Adults (18-65 years) Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from an environment, which is safe and comfortable. Evidence: The home is located in a popular residential area of Nutgrove, St Helens. It is close to local shops, pubs, cafes and medical centres. There are transport links close by with routes into St Helens Town Centre and Liverpool City Centre. The home is split up into a number of small units, which each comprise of several bedrooms, a lounge, bathroom and a separate toilet. The home also has a central lounge, dining room and a conservatory, which looks out over the well maintained and attractive back garden. On the day of the inspection visit all parts of the home were well maintained and very clean and tidy. The decoration, fittings and furniture were of a high standard. The home was comfortable and had a really nice homely feel to it. Residents were seen using all parts of the home including their bedrooms, the main lounge and kitchen. They were not stopped from using any parts of the home but for safety reasons, some residents need staff to support them while they are using certain parts of the home such as the kitchens. The reasons for this and the support the person needs was recorded in their individual care plan. Some improvements have been made to the environment since the last inspection visit making the home even more comfortable for the residents that live there. We were told in the AQAA about the things which Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: have been done since the last inspection, which included: Redecoration of the main lounge and dining room. Landscaping of gardens. Security gates have been fitted to the back of the building. Furniture and fittings have been replaced around the home. The AQAA told us that there are a number of up to date policies and procedures available at the home, which ensure the health safety and welfare of the residents and staff. The AQAA also gave us the dates of when equipment and safety checks were last carried out. These showed that all the required checks have been carried out at the right time. Some Health and safety checks were looked at such as fire safety tests, alarms emergency lighting, fire drills, these were up to date. There were no health and safety hazards noticed at the time of the inspection visit. Care Homes for Adults (18-65 years) Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Strict procedures are followed to make sure that the right staff are employed at the home and they receive training which is relevant to the work they do. Evidence: There were two care staff, a STAR worker, cook, domestic and a manager on duty at the time of the site visit, discussions took place with at least half the staff group. They were knowledgeable about the needs of the residents and showed a real commitment to ensuring the best possible care for them. All staff spoken with said they had received a copy of their job descriptions and clearly understood their roles and responsibilities. During the inspection staff were seen being sensitive and responsive towards residents needs, they listened and communicated well with them and showed a lot of patience when helping them. On the day of the site visit there appeared to be enough staff on duty to meet the needs of the residents. Staffing rotas which were looked at showed that there are at least three care staff on duty during the day and two staff at night. Staff spoken with said extra staff are brought in if they are needed and they think there is always enough staff on duty to meet the needs of the residents. One staff survey commented, The training for staff is excellent and there is always plenty of it. Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: Staff confirmed they receive a good level of training which is regular and relevant to their work. The AQAA told us that strict procedures are followed for employing new staff and that their personnel files are kept at the home and contain information to show that they are suitable for the job. Information provided in the AQAA and some training records which were looked at showed that they staff have completed or are planning to complete training which they need to have to work at the home. Staff spoken with said: We are offered a lot of training courses. The training is very good . The AQAA told us that All staff have an NVQ level 3 or are working to wards it. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is very well managed to the benefit of the residents and staff. Evidence: There has been a change of manager since the last key inspection visit. The company wrote to us to tell us about the change of manager and provided us with details of the her. In December 2008 the new manager Mrs Carol Edwards was approved by the Commission as the Registered manager of the home. Mrs Edwards has many years experience of working in care and is well qualified having achieved a number of relevant qualifications including NVQ Level 4 in care, the Registered Managers Award and a Bullet Proof Management award. The manager and other senior staff regularly attend training to update their knowledge which is relevant to their managerial roles. Comments received from people about the manager included: She is very good at her Job. The manager communicates well. The manager is positive and approachable. The home is very well managed. The manager was not on duty at the time of the inspection visit, the deputy manager and staff that were on duty helped with the inspection. The following comments were included in staff surveys: Our manager has Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: an open door policy if we need to speak to her. The management are always on hand to support and guide us. Making Space is a good, well organised company. The AQAA told us that there are a number of processes in place at the home for checking the quality of the service. They include regular reviews of all documentation, daily handover checks, visits to the home carried out by another manager that does not work there on a day to day basis and results of questionnaires, which are sent out to residents and their representatives at least twice a year. A selection of these records, which were looked at showed that effective quality monitoring processes are in place and improvements to the service are made if necessary. Also as part of the homes quality monitoring systems they voluntarily commissioned an independent body who awarded the home a 5 star rating for the quality of care to the residents, 5 star being the highest rating possible for this award. Details provided in the AQAA, evidence gathered during the site visit and discussion with people during the inspection showed that the home have in place all the records required by regulation and they are well maintained and kept up to date. The AQAA told us that there are up to date policies and procedures available at the home, which ensure the health, safety and welfare of the residents and staff. It also told us that the required checks are carried out when they should be on equipment and systems used at the home making sure they are safe. The AQAA told us that staff receive health and safety training in subjects such as fire awareness, moving and handling, first aid and food hygiene, the staff also told us this during the site visit. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 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 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) 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. 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