Inspection on 16/12/08 for Millview

This inspection was carried out on 16th December 2008.

CSCI found this care home to be providing an Good 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

Millview 19/12/06

Millview 12/09/05

Millview 03/05/05

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Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Millview 38 The Street Charlwood Horley Surrey RH6 0DF     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: Marion Weller     Date: 1 6 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Millview 38 The Street Charlwood Horley Surrey RH6 0DF 01293862443 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Prospect Housing and Support Services Type of registration: Number of places registered: care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 5. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home Millview is a detached house situated in the village of Charlwood, with a large and secluded garden to the rear of the property. Car parking facilities are available to the side and the front of the property. The home consists of five single bedrooms, which are decorated and furnished according to the service users choice. Bathroom and toileting facilities are situated on both floors. Stairs lead to the second floor of the home. Communal accommodation is on the ground floor and consists of a wellCare Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 5 Brief description of the care home equipped kitchen, dining room and lounge. A small pleasantly furnished conservatory is located to the side of the building with access from the lounge. The home owns a vehicle, which is used for service users to access community facilities and to participate in a range of outdoor activities. 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: The last key unannounced inspection of this service was completed on 19th December 2006. An annual service review was undertaken on 9th May 2008. Marion Weller, Regulatory Inspector, conducted this key inspection of Millview on 16th December 2008 from 10:30 am until 1:30pm. During the site visit the inspector spoke with some members of staff and the homes appointed manager. Due to the communication difficulties experienced by service users, direct views about their care could not be obtained. Parts of the home were toured and some records and documents were inspected. The inspection report takes into account all the information obtained about the service Care Homes for Adults (18-65 years) Page 6 of 30 since the previous site visit. This includes any formal notifications, phone calls and letters received and any complaints or allegations notified to the CSCI. The manager was asked to complete the homes Annual Quality Assurance Assessment (AQAA) prior to the inspection. The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical information about the service. The completed document provided relevant information that gave a clear picture of what was happening in the service and the plans for further development. Surveys were given to service users relatives, staff and other professionals involved with the home to find out their level of satisfaction, prior to the inspection taking place. Survey respondents were largely very satisfied with the care provided. Survey forms included the comments: ...I am fortunate to have my... (relative) in a small and personal home that is much more like a real home than an institution. ...Service users lead a meaningful life. And ...Well done and thank you to the staff. Your efforts are much appreciated. ...Millview provides a caring home from home for its residents. A survey respondent asked to comment on how the service could improve said, ...A little more exercise and a few more outings for its residents - difficult and costly I expect! Another respondent said,....perhaps more supervised walks and car journeys. Other statements made by survey respondents are included throughout the text of the report. No complaints have been made to the CSCI about this home since our last inspection, neither have we been involved in any safeguarding alerts in connection with Millview. The appointed manager and the staff gave their full cooperation throughout the site visit. What the care home does well: What has improved since the last inspection? What they could do better: Service users will benefit from the homes plans to add the services of an activity coordinator to the staff group. This will extend the scope of activities that are presently offered and will support individual service users for longer periods out in the community. Residents benefit from the appointment of a manager whose aim is to consistently improve and develop the services at Millview. They will benefit further when he has completed the fit person process and can evidence his responsibility for service outcomes. Care Homes for Adults (18-65 years) Page 8 of 30 The manager should access the CSCI website to seek further guidance on the reporting of notifiable events and incidents to fully comply with regulation and to safeguard service users welfare and best interests. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users and their relatives or representatives have all the information they need to make an informed decision about whether the service is right for them. Prospective service users also benefit from having their needs, choices and aspirations assessed prior to them making a firm decision to move in. Evidence: In line with a statutory requirement awarded at the last inspection the homes statement of purpose and service user guide has been revised and updated. The manager explained that the document is made available in formats that are suitable for the people for whom the home is intended. Due to the current residents communication difficulties it was not possible to gain their views about the information provided to them. No survey respondents however raised any concerns about the homes information documents and felt that they had received sufficient information to meet their needs. Survey respondents also recorded they were always kept up to date with important information about the service. Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: The organisations admission procedures are designed to ensure that potential service users are thoroughly needs assessed before a decision to move in is reached. The manager understood the pre admission procedure and explained the process. The pre admission assessment involves the individual, their family or representative and any professionals previously involved with the care of the individual. Where the assessment has been undertaken through care management arrangements, the service insists on receiving a summary of the assessment and a copy of the care plan. Prospective service users would be encouraged and supported to visit and spend time in the home, meet the staff and other service users and see their intended room. This process ensures that staff are confident they can meet the individuals needs and aspirations and compatibility has been established with the people already living in the home. There have been no new admissions to the home since the last site visit. The home continues to have one vacancy. Care Homes for Adults (18-65 years) Page 12 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are provided with an individual plan of care, which clearly records their individual needs and goals. They are supported to make decisions about their lives with assistance and support because staff have good information about them. In addition, service users are supported to take risks as part of an independent lifestyle. Evidence: The manager explained that Millview offers service users flexible routines, which are designed to support and enable the people living there to make individual choices wherever possible. The structure of a service users day is influenced and planned around their individual activities programme. The homes AQAA records, ...all service users are supported and encouraged to make their own choices. Staff support and involve them to participate in activities in the community. All service users had an individual care plan, which covered their choices and needs in Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: matters of personal care, health care, maintaining communication, behaviors, finance and social and spiritual needs. Individual plans were seen to be person centred, comprehensive and evidenced clear objectives and goals. They contained details of the individuals strengths, needs, likes and dislikes. The manager explained that it is the responsibility of the service users key worker to conduct reviews of their care plans and to keep them up to date. Care plans inspected clearly demonstrated that they were being regularly reviewed and updated. The manager said that practice had improved since the last inspection. As well as recording changes noted at review, key workers are now also making changes to the individuals main care plan. This ensures service users care plans remain current and up to date at all times. All service users have health action plans, which provide clear guidance for staff on meeting the individuals health care needs. Because of the limited speech of the service users living at Millview, staff base their decisions and reviews upon preexisting knowledge of the person and any new input received from relatives and other representatives. Risk assessments are in place and are being updated regularly to promote peoples lifestyle choices and to promote their safety. Any limitations on freedom, choice or facilities are always made in the persons best interests. Decisions made are documented and revisited during regular reviews. The manager was advised to secure additional advice and possibly a multi agency agreement to limitations placed on one individuals access to the homes normal facilities. The limitation was clearly noted to be in the individuals best interests however and to the benefit of other people living in the home. Care Homes for Adults (18-65 years) Page 14 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. Service users are encouraged and supported to take part in a range of age appropriate activities and to integrate in the local community. Service users will benefit from the planned provision of dedicated activity staff to enable more one to one working and prolonged periods of support for them when out in the community. The home is able to demonstrate that service users are provided with a well-balanced and nutritious diet. Evidence: Service users are encouraged and supported to take part in meaningful activities of their choice. There was evidence of the people living at Millview integrating into the local community with staff support. The home provides transport for clients and activity programmes evidenced their involvement with local leisure activities such as Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: bowling, horse riding, swimming and going to the pub and to the cinema. On the day of the inspection the service had arranged to go to a local restaurant for their Christmas celebration meal. The manager said that the service regularly organises day trips out and each service user is supported to have a holiday. The homes AQAA records, ....brochures are given to service users in order for them to make an informed choice about their holiday. When asked how the home could improve in this outcome area, two survey respondents commented. The first saying, ....perhaps more supervised walks and car journeys. Another respondent said,....a little more exercise and a few more outings, but I expect that is difficult and costly. The manager reported that the home has secured funding from Social Services to employ an activity coordinator who can support service users for longer hours when they are out in the community. In the homes AQAA the manager records his intention over the next 12 months to recruit an activity worker, to also spend more time with individual service users. All service users go food shopping supported by staff. The homes menu is available in a pictorial format to better inform staff of service users choices and needs. It was noted that fresh fruit and vegetables are included in menus on a daily basis to promote a healthy diet for people living at Millview. Links are maintained where possible with any known service users relatives and friends. Visits from relatives to Millview are encouraged. 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 able to demonstrate that service users receive personal support in the way they prefer and their physical and health needs are being met. People living at Millview are protected by sound medication administration procedures. Evidence: Individual plans of care clearly recorded service users personal and health care needs and detailed how these would be delivered. Care plans included the likes and dislikes of service users and their known preferences. The two care plans case tracked contained all the necessary information required for staff to offer appropriate and effective support and care to the service users. The manager records in the homes AQAA...alll care plans are up to date; they document the personal and health care support needed and a health action plan for each service user is in place for staff to follow. Service users access the local GP surgery with support from staff and attend well person checks annually and are offered flu jabs. Dental checks are organised six monthly and other interventions such as Chiropody and Optician appointments are Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: organised as necessary. Referrals for specialist treatment are made promptly by the home. The home has a policy on medication administration, which staff are clearly adhering to. No current service users are self medicating; reasons are recorded as to why the individuals are not able to carry out the activity for themselves. The manager records in the homes AQAA....all staff are trained to administer medication and to follow organisational policies and procedures. We have an annual audit visit by the local Pharmacist to ensure that safe practice exists in ordering, administration and storage of medication. We have received positive feedback from these audits. The provider organisation makes regular checks in relation to the homes medication administration systems, the results of which are recorded on regulation 26 reports. 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. The home is able to demonstrate that the views of service users are listened to and acted upon. Staff are suitably trained and understand the importance of local safeguarding adult procedures which ensures that vulnerable service users rights and best interests are safeguarded. Evidence: Systems are in place to ensure that people who live in the home and those that visit can make their views and concerns known. The home has a complaints procedure, which is also written in symbols to enable service users to understand it. A copy is given to service users to keep in their bedroom. The homes AQAA records.... all service users are encouraged to speak with the manager or their keyworker if they are unhappy about anything. They are aware that their views are always listened to and acted upon and we ensure that we give them feedback on issues raised. There have not been any formal complaints received by the home in the last 12 months. Our records show that the Commission has not received any complaints about this home in that time. The manager said they remain proactive in resolving any concerns raised with them at an early stage. Survey respondents recorded that they knew the homes procedures for dealing with complaints. There are sound procedures for responding to suspicion or evidence of abuse or Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: neglect to ensure the safety and protection of service users. The staff induction and NVQ training have elements of adult protection and there has been adult protection training for staff. The manager records that this is updated bi annually. The manager had a sound understanding of adult abuse and safeguarding procedures and stated any allegation of abuse would be referred to the concerned agencies without delay. The home has a copy of the updated Surrey multi agency safeguarding vulnerable adults procedures. There have not been any safeguarding alerts raised about people living in the home in the last 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users live in an attractive, well-maintained and safe environment that is also clean and hygienic. Evidence: Millview is a detached house situated in a village setting and is close to local shops and other amenities. The home has a large and very attractive rear garden, which is easily accessible from the house, and which the manager stated was well used by service users in the summer months. The front of the house provides limited car parking. The home is commendably clean and free from any offensive odours. It provides a physical environment that is appropriate to the specific needs of the people who live there. The house on this site visit had been nicely decorated in preparation for the coming Christmas celebrations. Apart from one service user who has special needs, service users bedrooms were seen to be bright and airy, warm and comfortable. The design of the house allows for a variety of shapes and sizes of rooms. Service users bedrooms are largely well personalised and have space to display personal possessions, store clothing, sit and relax and have a comfortable bed. The house has two communal bathrooms. There are comfortable and homely communal living areas provided with a good quality television Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: and other entertainment equipment available to service users. A survey respondent asked what the home does well said....it provides a caring home from home for its residents. In line with statutory requirements awarded in the last inspection report, the home has resolved the environmental issues detailed. The communal bathroom on the ground floor had been found to be very cold as the result of faulty radiator valve. This has since been replaced. In addition the overall decoration of the home was requiring basic remedial work in some areas. This work has now been done. The homes AQAA records ....we have a maintenance system in place and log all servicing. We have an annual improvement schedule which also includes decorations and budgeting for new equipment. Residents are protected from the risks of burns or scalds and radiators in the home have been covered. The manager stated that hot water outlets are all thermostatically controlled. There is a designated laundry that is suitably equipped, with systems in place to reduce the risks of cross infection. The home has a policy on infection control and has a contract in place for the disposal of clinical waste. Staff all receive training in infection control. COSHH safety data sheets and suitable risk assessments cover all cleaning products. It was noted that the fly screen over the kitchen window has now been replaced. All requirements awarded in the last inspection report have been satisfactorily resolved and will be removed from this one. 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. Service users are protected by the homes recruitment policy and practices and their needs are met by appropriately trained staff. Evidence: Survey forms included the comments: Well done to the staff, their efforts are much appreciated. And I find the staff friendly and caring. The home is staffed by a manager, an acting deputy manager and support staff. The manager said that vacancies on the duty rosters for permanent support staff have now been recruited to. An activity coordinator has also been appointed and the provider organisation is currently in the process of making POVA and CRB checks before the person commences working with service users. The home has access to bank staff that can offer roster cover. These individuals are known to the service user group and therefor offer them continuity of care in the absence of permanent staff. Throughout the site visit there was evidence of good relationships between staff and clients. Staff mentioned how much they liked working in the home and this was reflected in the way care and support was given. Staff obviously know service users Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: well and how best to meet their needs. There is an active key worker system in place. People applying to work at the home have to complete an application form, provide two references and have a POVA and Criminal Records Bureau (CRB) check and attend an interview. One staff survey contained the comment, .....checks were not in force when I stated in this work, but I have now had regular CRB checks. All new staff follows a recorded induction process and receives mandatory training. Regular update training is also provided for staff. In surveys staff recorded that induction offered by the home either met their needs very well or mostly met their needs. Millview is proactive in ensuring staff obtain NVQ qualifications. A number of staff already holds NVQ qualifications with others are undertaking the qualification on a planned programme. The home exceeds the 50 standard required for staff qualified at NVQ 2 or above. 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. Current management arrangements are meeting service users needs. The health safety and welfare of service uses is protected. Evidence: The registered managers post is currently vacant at Millview. A manager appointed in June 2008 by the provider organisation is running the home on a day-to-day basis. The appointed manager previously held the role of deputy manager at Millview. At the key inspection of the home undertaken in December 2006 it was reported that the registered manager at Millview had been seconded to another post in the organisation. There has been a considerable gap in the formal appointment of a replacement manager and the provider making application to register the individual. On this site visit it was noted that the appointed manager has applied for registration with the CSCI to confirm his fitness and to evidence his responsibility for service outcomes. One survey respondent commented,....sometimes there is a lapse between appointments of managers at Millview. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: The appointed manager was seen to be confident in his practice and has previous experience of working with people with learning disabilities. He is a qualified NVQ assessor and is currently undertaking his NVQ 4 in Care. He stated his intention to undertake the Registered Managers Award. The provider organisation has a policy on quality assurance and the manager said they use questionnaires to obtain feedback from all stakeholders involved with the service. The manager understands the principles of equal opportunity and diversity and applies the concept to his practice with clients and staff. He also evidenced a firm commitment to ensuring the health, welfare and safety of the people living in the home. A quality assurance manager carries out monthly Regulation 26 inspections on behalf of the provider. The subsequent reports of visits are comprehensive and detailed. There is a section for actions to be taken by the manager to resolve identified good practice shortfalls or issues of concern. Reports were also seen to record whether actions had been progressed in line with any statutory requirements awarded in inspection reports. The homes record keeping is effective and efficient with reviews of policies, procedures, information documents and systems of work to ensure they reflect current legislation and up to date good practice guidance. Records were seen to be kept in a manner that preserved confidentiality and safeguarded residents rights and best interests. The manager confirmed the home had regular meetings with staff and they encouraged service users to attend so that they can be as involved in the running of the home as their individual level of capacity allows. The homes AQAA evidences that staff have regular fire training and participate in fire drills at the required frequency. Fire exits were kept clear of obstructions and the manager said that fire fighting equipment is regularly serviced and maintained. In addition, the homes AQAA records that maintenance and safety checks are up to date. The manager records that he is the appointed person for the management of health and safety in the home and ensures that all policies and procedures are adhered to and service users are supported within a hazard fee environment. Water temperature testing is being regularly checked and recorded. All substances hazardous to health were stored and locked away appropriately. Records of accidents and incidents were being maintained appropriately. It was discussed with the manager that our records show we have not received any Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: Regulation 37 Notifications about accidents or incidents recorded in the home recently. The manager was advised to consult the CSCI website to inform and guide his practice as to the reporting of notifiable events to fully safeguard service users welfare and best interests. The home had received a visit from the Environmental Health Officer on 10th December 2008 to undertake a routine inspection. Two minor shortfalls were identified in the homes kitchen. The manager was able to evidence that both had been addressed to secure service users welfare. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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. 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