Inspection on 20/01/09 for Milbury 6 Milverton Road

This inspection was carried out on 20th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milbury 6 Milverton Road 05/05/06

Milbury 6 Milverton Road 23/11/05

Milbury 6 Milverton Road 21/04/05

Milbury 6 Milverton Road 22/10/04

Milbury 6 Milverton Road 30/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Milbury 6 Milverton Road 6 Milverton Road London NW6 6LH     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: User doesnt belongs to any group     Date: 2 0 0 1 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: Milbury 6 Milverton Road 6 Milverton Road London NW6 6LH 02084591140 02084591140 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Milbury Community Services Ltd care home 6 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 6 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 the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home 6 Milverton Road is located in a quite residential street in Willesden; the home is owned by Milbury Care Services and can accommodate six adults with a learning disability and physical disability. The home is closely located to Willesden High Street, Willesden library, cinema, pubs, cafes and restaurants. Willesden High Road has numerous bus rotes and Willesden Green is the closest tube station. 6 Milverton Road is a detached two-storey building. There is a large kitchen and lounge on the ground floor and access to the first floor is by a through floor passenger lift. People using the services rooms are located on the ground floor and first floor. There is parking in front of the house and a large well-maintained garden at the rear. Fees and charges can be obtained from the registered manager or operation manager on request. Care Homes for Adults (18-65 years) Page 4 of 30 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: 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: This unannounced key inspection took place during a day in January 2009 and lasted for six hours. The registered manager Mr Stephen McKenzie was not available during this inspection. The deputy manager Ms Buerger joined us during the early morning of this key inspection and was available throughout. We spoke with three members of staff and observed people using the service during this unannounced key inspection. We case tracked two people using the service and sampled care plans and other files made available to us on request. The home forwarded a very detailed Annual Quality Assurance Assessment. The home has a good track record of forwarding Regulation 26 records, which have been used by us prior to this inspection to make judgments about the service. We would like to thank people using the service, staff and deputy manager for their Care Homes for Adults (18-65 years) Page 6 of 30 help and support during this inspection. 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. New prospective people using the service are provided with detailed and accessible information about the care and service provided by the home. Evidence: This is what you told us in our Annual Quality Assurance Assessment: New prospective service users are offered introductory visits and an assessment of needs is undertaken by the homes manager. All people using the service are provided with a contract. We are planning to provide assessment information in a user friendly format. This is what we found during this inspection: We looked at the homes statement of purpose and service users guide, both documents have been updated in June 2008. The documents are very detailed. The home is using pictures to make the documents more accessible. We found both documents compliant with National Minimum Standards. Changes within the organisation have been included in both documents. The most recent inspection report and last annual service review is available on the notice board in the kitchen. Staff spoken to told us that they have read the most Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: recent inspection report. The home did not have any new admissions since the last key inspection. We looked at assessments during previous key inspections, which have been judged of good standard and compliant. Previous assessments can be accessed in a seperate care plan folder. We looked at three care plan folders during this inspection. All folders had contracts detailing fees, rights and responsibilities, terms and conditions, etc. Care plans have been signed by the next of kin, advocate or stated why they have not been signed. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are encouraged to take part in the care planning and risk assessment process. People using the service are supported to make decisions about their own lives and if they are happy with the care provided. Documents and records are made accessible to people using the service, by using pictures and symbols. Evidence: This is what you told us in your Annual Quality Assurance Assessment: We provide an individual plan based on the assessment of need, clearly indicating individualised procedures. The plan is drawn up with the involvement of the service user, family/friends/advocate and relevant agencies as appropriate. We provide an individualised service user guide which contains contact details of the relevant support agencies and this is reviewed with the involvement of service user, and or relevant support agencies. Service users are enabled and supported to make decisions in all areas of their lives. Involvement in the recruitment of staff, involvement in introductory visits of prospective new service users. Staff support service users to take Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: responsible assessed risks. Availability of confidentiality policy, confidentiality of information is incorporated in the induction and training of all staff members. This is what we found during this inspection: We assessed three care plans during this inspection. All support plans are detailed and have been reviewed during the past six months. Reviews were attended by people using the service, family members, advocates, clinicians such as Physiotherapist, key worker, home manager, etc. Short, medium and long term goals are reviewed and updated regularly. Cultural and spiritual needs are addressed in the care planning process. The home makes good use of pictures and symbols enabling the clients to take part in the care planning and review process. Care plan goals have very detailed guidance for staff, ensuring people using the service are consistently supported. Staff sign if they have read and understood the care plan. Staff spoken to confirmed that they involve people using the service in care planning and review processes. We viewed person centred plans, which uses pictures and symbols instead of words. The home has clear guidance in place, detailing why certain activities are not save for people using the service. We observed staff interacting with residents and felt that staff have good understanding of service users forms of communication. For example one person wanted to join us during the inspection and staff supported the person in this choice. We looked at two financial records, which were detailed. People using the service have their own bank account and income as well expenditure is clearly recorded. The manager and deputy manager check financial records regularly. The home has general and individual risk assessments for people using the service in place. All risk assessments viewed have been reviewed and updated in December 2008. Due to service users ability participation in the review process is limited. The deputy manager told us that risk assessments are reviewed during care plan reviews involving the family and/or advocates. We judged risk assessments as very detailed, staff sign once they have read and understood risk assessments. Staff spoken to confirmed this. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service attend activities appropriate to their age and culture. People using the service have good relationships with families and are supported making friends or having relationships. People using the service are provided with a varied and healthy diet and residents are given choices of different meal options. Evidence: This is what you told us in your Annual Quality Assurance Assessment: We provide Individual Activity Plans and Person Centered Plans. We facilitate attendance at external learning opportunities, access to behaviour therapist, enable service users to experience a wide range of leisure activities, support to continue with existing activities. Staff support service users to explore employment opportunities. We provide opportunities within individual activity plans to participate in the local community and provide highly trained staff in relevant areas. We maintain relationships with Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: neighbours, provide access to vehicles, assist and support in accessing local transport. We support people using the service to be politically aware and vote. A well balanced, varied diet is available based on individual preferences. This is what we found during this inspection: People living at Milverto Road are not in paid employment, this is due the complexity of their needs. People using the service access the Willesden Resource Centre on different days. During the day of this inspection two people attended the day centre. Activity plans viewed clearly state the days when people using the service attend the day centre. During the day of this inspection an aromatherapist visited the home. The therapist informed us that she visits the home twice a week. The aromatherapist told us, that staff is very helpful and will listen to her advice. The home is also visited regularly by two Physiotherapists. Staff told us that residents regularly visit the local community such as parks, cafes, etc. Daily records of people using the service did not fully confirm this. The deputy manager told us that she is aware of this and the home is currently in the process of addressing this. The home is providing their own public transport, but due to the lack of drivers there is limited use of this facility. The deputy manager and staff told us that the home has good relationships with their neighbours. One of the people using the service is visiting a Muslim group at the local mosque every Saturday, the group is attended by disabled on non disabled people. The home encourages regular family visits, visitor books, diaries and daily records confirmed this. For people without relatives the home is accessing local advocacy projects. Relatives are invited for birthday parties and other celebrations. The home has a detailed sexuality policy in place. Due to the nature of peoples ability residents do not have a key to the front door or their room. This is recorded in their care plans. Staff told us that people using the service are involved in household activities, which is depending on their ability. People using the service will observe staff when they are cleaning their room. The home is providing a varied and wholesome diet daily meals include fresh vegetable, fruit, pulses and meats. One resident is of Muslim faith; staff informed the inspector that meat is purchased from a Halal butcher. Alternatives are offered if pork or other non Halal products are on the menu. Fruit were available during this unannounced inspection. The home is displaying a picture of the meal on a notice board in the kitchen to show what meal is on the menu. A weekly menu is available and food choices are recorded in a separate book. Care Homes for Adults (18-65 years) Page 15 of 30 Care Homes for Adults (18-65 years) Page 16 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is supporting people using the service around health related issues and their health is clearly monitored. Detailed personal care guidance tells staff how people using the service prefer to be supported. Manual handling guidance is in place, but not followed, this could lead to people using the service and staff being injured. Evidence: This what you told us in your Annual Quality Assurance Assessment: We provide service users with the personal support they require in their preferred way. We meet the physical and health needs of the service user. This is what we found during this inspection: We viewed three support plans during this inspection, all plans contained detailed personal care guidelines. For example shaving, bathing, showering, getting up, etc. The guidance is up to date and the deputy manager told us that the home reviews guidance as part of the care planning review process. The home has a seperate portable hoist, a number of ceiling hoists and a bath for people who have mobility problems. Equipment is serviced six monthly and certificates of the servicing were viewed by us. The home has general hoist risk Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: assessments and individual manual handling risk assessments in place. The risk assessments have been reviewed on the 27/12/07 and state that hoists are only used by two trained members of staff. We spoke to three members of staff during this inspection including the deputy manager, who confirmed that it is common practice to hoist people using the service by one member of staff. This is of great concern. We left an immediate requirement form telling the home that this practice must stop with immediate effect. The registered manager and operation manager contacted us following this inspection. Informing us that they were surprised about this practice and told all staff that they must always use two members of staff when using a hoist. Staff has received Manual Handling refresher training on Friday the 30/01/09 and the registered manager has reviewed all risk assessments. A Physiotherapist is visiting the home weekly. The home has good links with Bernt Learning Disabilities Team and access to health care professionals is as and when needed. Records show that Speech and Language therapy, Occupational therapy and others have been involved with people using the service. All service users have an allocated key worker. We viewed detailed health care plans in care plan folders viewed. The health care plans is using pictures and symbols to make them more accessible. Health care plans are reviewed during care plan reviews. All people using the service are registered with their own General Practitioner, staff told us that the GP will visit if required. All people using the service have a seperate sheet with contact details in their file. Wheelchairs are serviced regularly. Staff told us that they accompany people using the service to health care appointments, which was clearly recorded. The home medication policy has been reviewed in June 2008 and was previously judged as compliant with National Minimum Standards. Requirements made by the CSCI pharmacy inspector in December 2005 has been complied with. The home is using a computerised training programme called EL-Box. All staff administering medication have undergone medication training and a signatory list of staff being competent in the administration of medication is in place. The home does not have any controlled drugs. We viewed detailed medication information informing staff of the side effects. PRN guidance is in place and a list of different routes and abbreviations used is in place. 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 using the service, family members and visitors are encouraged and supported to voice their satisfaction and dissatisfaction about the home. Robust adult protection procedures protect and support people using the service to make allegations of abuse. Evidence: This is what you told us in your Annual Quality Assurance Assessment: We provide a clear and effective complaints policy and ensure all service users are aware of its existence and how to use it. Complaints are dealt with in a specified time frame. Robust procedures for responding to any suspicion, allegation or evidence of any type of abuse are in place. Staff receive appropriate training in physical intervention. This is what we found during this inspection: The home did not receive any complaints since the last key inspection. Previous complaints have been dealt with and actions as well as outcomes of the complaints have been recorded. The complaints procedure is in place and available in the service users guide. Staff spoken to told us that they would inform the manager of any complaints made. Staff receive adult protection training during their induction. Training is provided by using the EL-Box learning programme. The home has an adult protection procedure, which has been reviewed in June 2008 in place. Previous adult protection allegations have been dealt with according to local adult protection guidelines. The home is Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: planning to provide a more accessible adult protection policy within the next twelve months. 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 using the service live in a nicely decorated, clean and homely environment. Evidence: This is what you told us in your Annual Quality Assurance Assessment: We provide an accessible, homely, clean, hygienic, safe, well maintained, and comfortable environment to meet individual service users needs and current legislation. We provide all people using the service with their own personal space in a self contained single rooms, with suitable furniture and fittings and encourage/support to add their own personal belongings that reflect their culture, beliefs and personalities. We provide appropriate accessible laundry facilities that meet with current requirements. We provide comfortable and fully accessible communal facilities that reflect service users needs and preferences, with aids and adaptations as necessary. This is what we found during this inspection: The deputy manager showed us around the home. The home is overall nicely decorated, the furniture in the ground floor lounge have been replaced since the last key inspection. Requirements made during the last key inspection have been resolved. We viewed one of the service users rooms, which was nicely decorated, pictures and ornaments reflect the cultural and religious background of the person. Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: The homes laundry area is spacious and can be accessed through the lounge and hallway. Floors and walls are of good standard and can be cleaned if necessary. The home has a semi professional washing machine and clothes dryer; both machines were of good working order. The COSSH cupboard under the sink in the laundry area was closed. The home was free of any offensive odours and clean during this inspection. The home has robust health and safety policies and procedures in place; in addition to this a number of health and safety leaflets were displayed on the notice board in the kitchen to raise awareness and provide information to staff, service users and visitors. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A strong and competent staff team supports people using the service. Robust recruitment practices provide service users with an appropriately vetted staff team. Staff receive appropriate training enabling them to support residents to high standards. The registered manager is supervising staff, but these supervisions should be arranged more regularly. Evidence: This is what you told us in your Annual Quality Assurance Assessment: Staff have clear roles and responsibilities. Staff are appropriately trained and qualified. We provide a robust recruitment policy and practice adhering to relevant current standards and legislation. All staff are supervised and appraised on a regular basis. Staff receive paid training days. This is what we found during this inspection: We found three staff on duty during the day of this inspection. The rota stated that three staff work during the morning, three staff during the afternoon and two staff during the night. Staff told me that they are satisfied with the staffing ratio and people using the service appeared well cared for. The home does not employ staff under the age of 18 years. Training records show that staff have received different levels of training, this is depending of the lengths of Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: service with the organisation. We looked at eight training files, two out of the eight files had evidence of National Vocational Qualifications in Care (NVQ). We spoke to the registered manager about this and told him that access to NVQ training is now free. He explained to us that the home had difficulties in finding assessors, this however has now been resolved and he is planning to enroll staff in NVQ training. We looked at three staffing files in detail, all relevant recruitment information was in place. The home has a recruitment procedure in place, and processes have been followed. Staff spoken to confirmed that they had to provide documentation for Criminal Records Checks and addresses of referees, which have been approached prior to a permanent post was offered. The deputy manager told us that training records are updated every months. All training attended is recorded on the EL-Box. Each user has an individual account, which is password protected. The account can be accessed by the manager for monitoring purposes. Staff have mixed opinions of the use of EL-box and told us that it is good to access training, but it sometimes is very isolating, which may not suit everyone. Staff told us that they have told this the manager, who is feeding back to the training department. Training is provided in three stages; induction, mandatory and specific training. Staff have different levels of skills which is depending of the time in post. We looked at supervision records of eight members of staff. Not all staff have received the minimum number of six planned supervisions per year. The deputy manager told us that she is currently not providing any supervisions to staff. She also told us that she did not receive a planned supervision, since transferring from another home. Staff confirmed of having attended team-meetings, the last recorded team meeting was held in October 2008. The rota indicated that a team meeting is planned for February 2009. 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. An approachable and experienced manager manages the home. People using the service, staff, stakeholders are regularly consulted about the home and peoples Health and Safety is not compromised. Evidence: This is what you told us in your Annual Quality Assurance Assessment: Service users live in a well run home with an effective manager that respects the individuals rights and ensures their best interests are safeguarded. People using the service views underpin monthly monitoring and annual service reviews, polices and procedures are in place to ensure the health, safety and welfare of service users are protected and ensure that record keeping is of a standard required by the regulating body, legislation and policies and procedures of the organisation. This is what we found during this inspection: The registered manager Mr Stephen McKenzie is still in the process of obtaining his Registered Managers Award qualification. He informed us that there has been some problems with work based Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: assessors. The manager is very experienced and staff informed us that the manager is a good listener, supportive and very helpful. We feel that the registered manager could delegate tasks to senior staff allowing him to file and re-organise the office, which is very unorganised. A valid insurance certificate and Registration certificate has been displayed. The home has an annual development plan in place and people using the service, staff and stakeholders are invited filling out confidential questionnaires to voice their perception of the service. We have received a very detailed and completed Annual Quality Assurance Assessment, information has been used throughout this report. The home has an excellent track record of regularly forwarding a regulation 26 report. As mentioned earlier the home must ensure that staff meetings are held more regularly. The home has a robust Health and Safety policy in place. All staff have attended fire training, the fire equipment and fire alarm has been serviced on the 7th October 2008, fire drills are done quarterly, the manager inducts all staff in how to use the fire panel and the fire risk assessment is up to date. Certificates viewed by us are in good order and none of the certificates have expired. 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 32 18 The responsible person must 01/04/2009 ensure that a minimum of 50 of staff employed hold National Vocational Qualifications in Care Level 2 or equivalent. This ensures only appropriately qualified staff support people using the service. 2 36 18 The responsible person must 01/03/2009 ensure all staff receive a minimum of six supervisions per year, pro rata for part time staff. This ensures appropriately supervised staff supports people using the service. 3 37 9 The responsible person must 01/04/2009 ensure that the registered manager is completing his Registered Managers Award. Care Homes for Adults (18-65 years) Page 28 of 30 This ensures a qualified manager is supporting people using the service and staff. 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 13 13 The responsible person should ensure that clear activity records of people using the service are maintained. The responsible person should find better ways enabling people using the service to have more frequent access to the homes vehicle. The responsible person should tidy up and re-organise the filling system, to make it easier to access for staff and people using the service. The responsible person should maintain and arrange regular team-meetings, ensuring staff are supported appropriately to care for people using the service. 3 37 4 37 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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