Inspection on 25/02/09 for Hilltop

This inspection was carried out on 25th 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

Hilltop 07/03/07

Hilltop 28/02/06

Hilltop 02/11/05

Hilltop 07/03/05

Hilltop 11/05/04

Hilltop 16/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Hilltop Ridge Walk Ruardean Hill Drybrook Glos GL17 9AY     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: Lynne Bennett     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 30 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.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: Hilltop Ridge Walk Ruardean Hill Drybrook Glos GL17 9AY 01594542026 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): hilltop@orchard-trust.org.uk The Orchard Trust Name of registered manager (if applicable) Mrs Jillian Mary Malsom 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 who can be accommodated is 6. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection Brief description of the care home Hilltop is a purpose built detached six-bedroom house situated in the Forest of Dean. The home is part of Orchard Trust and has other homes within the area. The home currently provides permanent residential care and respite care for adults with learning and physical disabilities. The home provides an additional respite day care service to people from neighbouring areas. The respite service is funded by Gloucestershire Community and Adult Care Directorate on a block-funding basis. Fees for people living in the home commence at 1,032 pounds per week. Prospective people and others involved in their care are offered information about the home including copies of the Care Homes for Adults (18-65 years) Page 4 of 30 care home 6 Over 65 0 6 Brief description of the care home Statement of Purpose and Service Users Guide. 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: 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: This inspection took place in February 2009 and involved two visits to the home on the 25th and 26th February by one inspector. The registered manager was present throughout the visits. She had completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). Surveys were received from two people who stay at the home, one member of staff and two health care professionals. All three people who live permanently at the home were met and time was spent observing the care and support they received. Two other people staying for respite were also spoken with. A visiting health care professional Care Homes for Adults (18-65 years) Page 6 of 30 gave us some feedback. Five members of staff were spoken with during the visits. A selection of records were examined which included staff files, health and safety records, quality assurance audits and medication systems. We talked to 4 people using the service, and asked staff about those peoples needs.We also looked at the care plans, medical records and daily notes for these 4 people. This is called case tracking. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. 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.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to the information they need enabling them to make a decision about whether they wish to live at the home or use the respite service. A comprehensive assessment of the persons wishes and needs are taken into consideration before offering them a place. Evidence: The homes Statement of Purpose and Service User Guide had been reviewed in 2008. The Service User Guide was produced in a format appropriate to peoples needs using text, pictures and photographs. Both documents were accessible to people in the entrance hallway of the home. Two people had recently moved into the home long term and one new person had been admitted to use the respite service. There was evidence that they had been fully assessed by the home and an assessment and current care plan had been obtained from the placing authority. Both people who moved into the home had previously used the respite service. People wishing to use the respite service were invited to visit the Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: home with their family or carers and to meet with other people using the service. There was evidence that the registered manager had confirmed with people wishing to move into the home that their needs could be met. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are being involved in developing their care plans that reflect their aspirations and needs. Imaginative use of resources enables people to express their wishes and needs. Risks are being managed safeguarding them from possible harm. Evidence: A person centred approach to care planning was in place involving people with the identification of their wishes and aspirations. Each person had a holistic assessment of needs in place from which person centred plans were developed for their physical, emotional, social and intellectual needs. There was evidence that annual reviews were taking place and most of these were being held with the day centres which people attended during the week. Care plans were being reviewed by key workers each month. Plans were clear and succinct providing staff with guidance about how people wished to be supported. Where care plans referred to other records such as Physiotherapy guidelines or as necessary (PRN) protocols, copies of these were included with the care plan. Staff spoken with had a good understanding of the needs Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: of the people they were supporting and were observed following care plans. For instance, one persons mobility care plan stated that they should be encouraged to change their position frequently. They were observed being supported to transfer from their wheelchair to an ordinary chair. Some care plans were illustrated with photographs of the person providing staff with a clear picture of the support they needed. Staff said that systems were in place for people using the respite service to check with their family or carers prior to each visit whether there had been any changes in their needs since the last stay at the home. A communication book and handover ensured that this information was passed to the staff team. Daily notes were also being kept which were supplemented by comprehensive monitoring records. There was information in the home about local advocacy services and there was evidence that one person living in the home had an advocate. Where there were any restrictions to peoples freedom around the home, such as access to the kitchen when no staff were present, were recorded in their individual contract or terms and conditions. Where bed rails were being used a risk assessment had been put in place indicating the reasons for their use. There were excellent systems in place to enable people to understand information and records provided by the home and to express their wishes and needs. Photographs were used to illustrate documents and on notice boards providing information about staff on duty, activities and meals. Some people had visual prompts in their rooms to enable them to be independent with their personal care. Peoples likes and dislikes were represented in pictures and photographs in their files. Staff were observed using makaton sign language. The AQAA stated, More symbol format to be used in all documents relating to people who use the service. Where people needed support to manage their personal finances this was provided and care plans reflected this. A risk assessment checklist was in place for each person identifying possible hazards and from this individualised risk assessments had been developed. These were being reviewed each month by key workers. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. Evidence: A member of staff said they had taken responsibility for arranging activities and were hoping to attend an activities course. There were some excellent outcomes in this area. Staff were using imaginative methods to communicate opportunities and choices to people. Activities people enjoyed were included in the pictoral record of their likes and dislikes as well as being identified in their care plan. Daily records included reference to activities people had taken part in during their day and individual activity records were also being completed. One person staying for respite said they continued Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: to go to college. Others were observed going to day centres or the Orchard Trusts day care facility known as The Barn. Staff said people enjoyed going shopping or to the local pub at weekends. One person living in the home went out shopping and for lunch during our visit. People were observed being supported to do arts and crafts and being offered choices about the activity they could participate in. One person chose to do a puzzle and others spent time in a sensory environment in the quiet lounge. Staff said that people were supported to go to a social club one evening a week. People living in the home were planning their holidays for later in the year. People were supported to help out around the home with the cleaning, laundry and cooking or baking. People staying for respite said they chose not to be involved in day to day tasks but might help out with cooking. People living in the home were observed participating in the preparation of the evening meal. Care plans indicated they were supported to maintain daily living skills such as helping with the laundry or cooking. People were invited to take part in house meetings which were going to be held every couple of months. Minutes of these meetings were being kept and were accessible to people. People were observed choosing where to spend their time and with who, making full use of all communal areas of the home. Some chose to do arts and crafts in the dining room, watch television in the lounge, relax in the sensory environment of the quiet lounge or spend time in their room. Staff support was available for people if wanted. People living in the home were being supported to maintain regular contact with family and friends. Records indicated whether they had visited them or visits had been made to the home. One person staying for respite asked if they could telephone their mother and records indicated that they had done this the evening of our visit. Staff confirmed that people staying for respite could book stays when their friends were staying in the home. There were excellent outcomes for peoples dietary needs. A member of staff had interviewed the three people who live in the home and all people staying for respite before producing a roll over menu. This had been produced in a format using photographs and pictures and was displayed for people to read. The meals for the day were also recorded on a white board. People said they liked the food and were observed having a beef stew one evening and choosing their lunch during another visit. Staff confirmed that meals were freshly produced using fresh ingredients. Fresh fruit was provided for people to snack on and people were observed having frequent drinks. Special diets were being catered for and where people needed a soft diet staff said that these were presented in an appetising way. Detailed records were being kept of what people had eaten and their fluid intake was being monitored where needed. Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: One person liked to have the occasional drink of wine or sherry and this was being provided. Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal care support is offered in a way that responds to peoples needs and preferences, promoting peoples dignity. Medication systems are being reviewed and discussed with other health care professionals to make sure they are robust and medication administered in the best interests of people. Evidence: Care plans indicated What you need to know and do to successfully support me. They provided staff with clear and succinct guidance about peoples preferences for support with their personal care. Plans did not identify whether people would like to be supported by male or female staff. Despite this staff felt that where peoples preferences were know they would be respected. The majority of staff were female but male support was available. Staff spoken with had a good understanding of peoples needs. They said that close working with day centres and other healthcare professionals was vital to ensuring consistency and continuity of care for people staying for respite. Feedback from healthcare professionals indicated that staff followed advice and kept them informed of changes. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: Excellent systems were in place to enable people to express how they would like their needs to be met. By using personalised photographs, pictures and symbol people could express their likes and dislikes. People living in the home had records in place providing evidence of regular access to a range of healthcare professionals. Outcomes of appointments were recorded. Health action plans were in place for people living in the home and there was evidence of annual well being checks with their Doctor. The home works closely with the local Community Learning Disability Team and monitoring forms required by them and other healthcare professionals were in place. Systems for the administration of medication were examined. Staff confirmed that they had received training in the safe handling of medication and had refresher courses every three years. The registered manager was advised to implement annual competency audits for staff. A signature list was in place of staff administering medication. Staff described the way in which they gave medication to people. This was satisfactory. The temperature of the cabinet was being monitored and recorded. Creams and liquids were labelled with the date of opening. Systems were in place for checking in medication for people staying for respite. This was sent to the home in the original packaging. Records indicated that where staff had queries about their medication they contacted the Doctor and two staff recorded their comments. The area manager confirmed that new forms had been developed for the use of homely remedies by people staying on respite. Handwritten entries on the medication record must be signed and checked by a second member of staff to verify that they are correct. Records indicated that medication for one person was being given to them on a spoon and that for another person in their coffee. The Doctor had authorised this covert administration of medication. The area manager confirmed that assessment of capacity forms, in line with the Mental Capacity Act, were being developed and that these would be discussed with the Doctor, Speech and Language Therapist and/or Pharmacist to evidence that this was being done in the persons best interests. Protocols were in place for the administration of PRN medication. Although shortfalls were identified in the administration of medication it was evident that Orchard Trust were taking steps to ensure systems were robust and people were being safeguarded from possible harm. Care Homes for Adults (18-65 years) Page 18 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that should safeguard people from possible harm or abuse. Evidence: A copy of the complaints procedure was in the office at the time of the visits. The Service User Guide in the hallway made reference to this document but was not accessible to people living in the home. The deputy manager said that a copy would be placed in the hall. The procedure had been produced in a version accessible to people using text, pictures and symbols. The home had not received any complaints. The management team said that if they received any concerns they dealt with them straight away but this rarely happened. Copies of compliments received by the home were displayed in the hallway. Comments included, thankyou for your help and support, you will do everything you can to make my daughter happy and make.... feel special. Surveys from people using the service indicated that they knew how to make a complaint. One person staying for respite said they would talk to staff. They expressed a concern to us during the visit and were then heard telling staff. On the next visit they confirmed that action had been taken by staff to address their concerns. People were able to also express any concerns they may have in the house meetings which were scheduled to be held every two months. Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: Staff confirmed that they had completed training in the safeguarding of adults and mental capacity act. Staff spoken with had a good understanding of abuse, what they should look for and the action they would take if they suspected someone was at risk. The management team have worked with the local adult protection team. A copy of their procedures were in the home. Accidents and incidents within the home were being recorded and monitored. Staff confirmed that they do not use physical intervention in the home and that they would need to have the appropriate training should they need to use it. Care plans were in place for some people who needed support from staff to manage their anxieties. For one person this indicated allowing space and time to express themselves. Staff were observed doing this during our visit. As noted earlier, any restrictions were recorded and the rationale for these noted. It was not apparent however how people had been involved in the decision making process such as the use of bed rails. Consent should be recorded indicating how people were involved in these decisions. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is safe, clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements..Specialist equipment is provided to those people who need it. Evidence: Hilltop provides comfortable, clean and well maintained accessible accomodation for people with a physical disability. Communal areas around the home including the garden were fully accessible to people. A new sensory garden was being planned and this too will have a ramp so that people with a physical disability can use this area. Specialist adaptations had been provided in peoples rooms and bathrooms. People living in the home had been involved in choosing the colour schemes. Photographs of this process evidenced peoples involvement from looking at colour charts to buying paint. The registered manager confirmed day to day maintenance support and a longer term maintenance plan were in place. Good infection control procedures were in place. Staff had access to personal protective equipment. Liquid soap and paper towels were supplied in communal toilets and communal hand washing basins. Hazardous products were stored securely. Appropriate infection control measures were in place in the laundry. Care Homes for Adults (18-65 years) Page 21 of 30 Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are met by a competent staff team,who have access to a satisfactory training programme that provides staff with knowledge about the diverse needs of people living at the home. Recruitment and selection procedures should safeguard people from possible harm. Evidence: The AQAA confirmed that over 60 per cent of the staff team had a National Vocational Qualification (NVQ) in Health and Social Care and that the same number had completed a Learning Disability Qualification(LDQ). Staff confirmed that after completing the homes induction they completed the LDQ. This is excellent and exceeds the National Minimum Standards. Staff spoken with were knowledgeable about the needs of the people they support and had the skills and experience to meet their needs. Staff were observed treating people with dignity, respect and patience. Relationships appeared to be positive and professional. Staff spoken with were aware of their professional boundaries. Recruitment and selection for new staff was examined and found to be mostly satisfactory. Application forms asked for a full employment history and where this had not been provided there was evidence that this had been obtained providing a record Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: of any gaps. People were not being appointed until two satisfactory references and a Criminal Records Bureau check were obtained. One person had worked for another care provider and the reason for leaving this employ had not been obtained. They had worked for a number of employers over a short period of time. The registered manager was advised that they should verify this. Proof of identity was obtained and copies kept on staff files. Photocopies of birth certificates and a CRB check should not be kept but receipt can be recorded on the checklist at the front of each file. Copies of training certificates were in place. The registered manager said that one person living in the home had been involved in an interview for a new member of staff. This is excellent practice. The Orchard Trust has a robust training programme in place for staff who said they were actively encouraged to complete all mandatory training and any training specific to peoples needs. In 2008 staff had also completed autism awareness training, oral health care, epilepsy awareness and a Diabetic workshop. Where staff had specific responsibility for key areas such as health and safety, fire or activities they were being provided with the appropriate training. The registered manager said that bank staff had not completed all mandatory training. All staff working in the home should have the competencies, knowledge and skills to support people. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect. Effective quality assurance audits will be in place involving people who live at the home. Systems are in place to maintain and monitor the health, safety and welfare of people. Evidence: The registered manager has considerable experience in this field and had completed the Registered Managers Award. She said she had almost finished her NVQ Level 4 in Health and Social Care. Staff spoke positively about the management of the home, their accessibility and openness. The registered manager had completed the AQAA comprehensively and forwarded it to us before the required date. She keeps in touch with us informing us of any incidents within the home as required under Regulation 37. The Orchard Trust were introducing a new Quality Management System in accordance with ISO 9001 which it stated would provide a periodic and systematic review of quality assurance procedures. Monthly unannounced visits to the home take place Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: each month in accordance with the Regulation 26 visits required by us. The Orchard Trust was awarded the ISO 14001 - Environmental and ISO 9001 - Quality Assurance in 2008. The registered manager said she would send out a questionnaire to people using the service in 2009. Copies of the 2008 survey were inspected. One person stated, I have always found everything satisfactory. Senior staff were also completing weekly audits around all systems in the home noting any shortfalls and recording any actions taken. Systems for monitoring health and safety within the home were robust. Regular checks were seen to be in place for fire, food hygiene checks, water/legionella and maintaining any specialist equipment or adaptations. A fire risk assessment was in place which indicated a full evacuation of people from the home in case of fire. A matrix was displayed in the office indicating servicing of equipment and utilities in the home. The Orchard Trust has a health and safety committee which a representative from the home attended to discuss concerns and good practice. Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 Where medication is 04/05/2009 administered with food, evidence must be provided of discussion and agreement by a multi disciplinary team that this is in the best interests of people. This is make sure that medication is administered safely and in the best interests of the person. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 3 20 20 23 Staff should have annual competency checks in place for the administration of medication. Handwritten entries must be signed and checked and countersigned by a second member of staff. Where restrictions are in place records should evidence how people have been involved in this process, with respect to the requirements of the Mental Capacity Act. Photocopies of Birth Certificates and CRB checks should not Page 28 of 30 4 34 Care Homes for Adults (18-65 years) be taken. 5 34 Bank or relief staff should complete all mandatory training. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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