Inspection on 18/03/09 for Nottingham Neurodisability Service Hucknall - Millwood

This inspection was carried out on 18th March 2009.

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

Nottingham Neurodisability... 01/04/08

Nottingham Neurodisability... 20/09/07

Nottingham Neurodisability... 06/11/06

Nottingham Neurodisability... 08/12/05

Nottingham Neurodisability... 14/07/05

Nottingham Neurodisability... 31/01/05

Nottingham Neurodisability... 02/08/04

Nottingham Neurodisability... 03/03/04

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: Nottingham Neurodisability Service Hucknall - Millwood Hankin Street Hucknall Nottingham NG15 7RR     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: Angela Starr     Date: 1 8 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Nottingham Neurodisability Service Hucknall Millwood Hankin Street Hucknall Nottingham NG15 7RR 01159680202 01159642747 sandra.horton@fshc.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Four Seasons Homes (Ilkeston) Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 22 Number of places (if applicable): Under 65 Over 65 0 physical disability Additional conditions: 22 Nottingham Neurodisability Service Hucknall - Millwood is registered to provide personal care with nursing to male and female service users who fall within the following categories :- Physical Disability (PD) 22 The maximum number of persons to be accommodated at the Nottingham Neurodisability Service Hucknall - Millwood is 22 Date of last inspection Brief description of the care home Millwood care home provides personal care and accommodation for 20 younger adults who have an acquired traumatic brain injury. The home is owned by Four Seasons, which is run as a small business. The home is one of 3 registered homes on the same campus located in a residential area of Hucknall close to shops, pubs, the post office and other amenities. The home was opened in 1995 and consists of a purpose built 2-storey building. All of Care Homes for Adults (18-65 years) Page 4 of 29 Brief description of the care home the homes bedrooms are single occupancy, and 11 of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors and there is a passenger lift to access the first floor. The home has a small patio area and there is ample car parking space available. The fees currently charged at the home range from 1,514.00 pounds and 10 pence per week to 2,200 pounds per week. Special care and 1-1 care is at the cost of 20.00 per hour. These costs do not include the costs of hairdressing, toiletries and chiropody. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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 focus of Inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people who use the services and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. We have introduced a new way of working with owners and managers. We ask them to fill in a questionnaire called an Annual Quality Assurance Assessment, which tells us about how well their service provides for the needs of the people who use it and how they intend to improve their service. Care Homes for Adults (18-65 years) Page 6 of 29 We received this back from the manager within the required timescale and the form was completed in a satisfactory manner, providing us with information to assist in planning our visit and deciding what areas to look at. We also reviewed all the information we have received about the service since we last completed a key inspection on 1st April 2008 and we considered this in planning the visit and deciding what areas to look at. The main method of Inspection we use is called case tracking which involves us selecting a number of people who use the service and looking at the quality of the care they receive by speaking with them, observation, reading their records and asking staff about their needs. We also sent Have Your Say questionnaires to a random selection of people who use the service, some relatives and some staff members. The information provided in the replies we received, was also a contributory factor in the focus of our inspection visit. We spoke with three members of staff, three people who use the service and two relatives to form an opinion about the quality of the service being provided. We read documents as part of this visit and we conducted a partial pharmacy audit to form an opinion about the health and safety of people who use the service. A copy of the latest inspection report can be found on the web site at www.csci.org.uk What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with the necessary information to enable them to make an informed choice. People have their needs assessed prior to admission to the service which ensures that each persons needs can be met. Evidence: The unit manager told us in the written information he provided, We ensure that all potential residents and their families are given the opportunity to visit the unit at their convenience, as many times as they need to. They are given time to talk with staff and ask as many questions as they wish. This approach is aimed at empowering key people in the decision making process. We looked at the information given to people when they make an initial enquiry. This included the statement of purpose and service user guide. Both of these documents have been reviewed and up-dated as recently as February and March 2009 and were displayed in the entrance hall, along with a copy of the last inspection report and the Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: complaints procedure. As part of our case tracking process, we looked at the care files of three people living at the service, including the last person to be admitted. All three files contained copies of the above mentioned documents. The manager told us that each person has a thorough and robust pre admission assessment completed to ensure that their needs can be met at Millwood. This is done prior to any placement being offered. The files we saw all contained a copy of this assessment and a thorough and detailed care support plan which had been developed with the person within the first week of them living at the service. Nutrition, hydration and skin integrity had been assessed and planned for within the first three days. These plans were comprehensive and detailed enough to provide staff with all the information they required to enable them to deliver the appropriate care in the manner preferred by each person. We received six questionnaires back from people who live at the service. Where we asked Were you asked if you wanted to move into this home? Five replied yes and one replied no. A comment received said I was not able to make the decision at the time. We also asked Did you get enough information about this home before you moved in? Four people said Yes and two said No. Comments included, I had all the information from Social Services and My family dealt with this. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good 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 service have their personal and health care needs assessed and met. Evidence: The unit manager told us in the written information he provided The recent introduction of a care culture based on empowerment and choice is starting to proactively involve residents in their care planning and choices regarding the structure of their day. The documentation we looked at showed us that care plans were developed in conjunction with the person and/or their relatives. Dignity and respect had been considered throughout and each persons mental capacity had been assessed and taken into consideration. As part of our case tracking process we looked at the care files for three people who Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: live at the service. All three files contained detailed and comprehensive care plans which had been developed and reviewed in conjunction with the person and their relative as far as possible. The care plans were developed in a person centred manner, with reference to peoples choices and needs. Relevant risk assessments were in place and were reviewed and up to date. The risk assessments we saw provided evidence that people are encouraged and supported to take acceptable risks and make decisions that enable them to maximise their independence. Care files also provided evidence that people have access to community facilities for dental care, optical care and that their health needs are met by Doctors and Specialist Practitioners where necessary. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Millwood experience a fulfilling life as far as is possible. Individual goals are identified and people are enabled to make choices and exercise preference. Evidence: As part of our case tracking process we looked at the care files for three people who live at the service. All three files contained detailed and comprehensive care plans which had been developed in conjunction with the person and their relative as far as possible. The care plans were developed in a person centred manner, with reference to peoples choices and needs. Dignity and respect had been considered throughout. The unit manager told us in the written information he provided All residents have in place an individual care plan based on the activities they have chosen to participate in. Residents are encouraged to set their own daily routines and all are encouraged to Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: access services in the community such as dentist, sports facilities, hairdressers etc. We have open visiting hours where residents can choose to receive visitors or not. This information also told us There is a varied and specialist menu available for people and within this, snacks are available 24 hrs a day if needed. We undertook a partial tour of the premises and saw that most people had brought personal possessions into the home and their rooms were decorated in a style of their choice. Our surveys asked people Does the care home give the support or care to your relative that you expect? We received four replies. Two said always and two said usually. Comments included Absolutely. and Yes, they show my relative great care and support. A relative we spoke with told us I have been visiting here for years and they have always looked after my relative very well. They treat my relative and me with dignity and respect. When my relative came here, they sat and discussed all their likes and dislikes and I am always consulted. We looked at the menus and saw that a choice is offered to people at lunch time and tea time. The food offered is varied and there is always a vegetarian option. Snacks are available in the evenings and at any time they are required. There is a dining room and we observed people having their lunch. Some people who needed assistance were being supported in a discreet and caring manner. On the day of the inspection the people living at the service were able to discuss their particular likes, dislikes and preferences with us. People told us I do what I want to do. There is plenty to do. I like going out best. Two activities co-ordinators are employed for a total of sixty hours per week and provide support over seven days. They spend time with each person to discuss their likes and dislikes, their preferences and any specific activities they would like to pursue. The service provides a comprehensive range of activities in-house and in the wider community, including bowling, swimming, shopping trips and visits to the pub. People are consulted individually and in residents meetings about things they would like to do. Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: One person we spoke with said I like to spend time watching telly. Another person said they like to go out walking and to the park. We saw minutes of a recent meeting and noted that people were asking to attend the local gym and to establish a health awareness group. People were also asking for menus to be on dining tables to refresh their memories about what they are being offered to eat. We looked at the menus and noted that people are offered a choice of healthy and appetising food. We observed people having lunch and one person said with regard to the food Ill give it 9 out of 10. We also spoke with some relatives to gain an understanding of how the service assesses and then meets any identified social needs. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are receiving personal and healthcare support in the way they prefer and require. Their health care needs are being met. Evidence: We case tracked three people who live at the service and looked at their care files. All contained thorough support plans that had been reviewed each month and any identified changes addressed. There was evidence in all the files that people had been consulted as far as possible about their care and how they prefer to be supported. People have an initial review after 4-6 weeks of living at Millwood and this is attended by family members, any involved professionals and staff from Millwood. At this point, any problems or necessary changes are addressed and then monitored through the monthly care plan evaluations. Each care file contained a Care & Health assessment profile detailing all aspects of the persons needs. Any necessary consent forms are signed and kept in the care file. Daily records are kept in a separate folder for staff to access throughout each shift. These Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: records were up to date and contained enough detail to enable the sharing of information between shifts. People are weighed monthly unless they refuse. Any concerns about change in weight are referred to the persons Doctor as soon as they are indentified. All care plans were in place and had been reviewed monthly with any identified changes recorded and met. Assessments for Mental Capacity were also present in each file and identified the persons ability to make day to day or complex decisions. Doctors and other professional visits were recorded on each persons file and there was evidence that people have good access to any specialist services they may require, including speech and language therapy and physiotherapy. From the pre- assessment, a thorough and detailed care support plan is developed with the person within the first week of them living at the service. Nutrition, hydration and skin integrity is assessed and planned for within the first three days. There are currently no people living at Millwood who are administering their own medication. However, the care files we looked at showed evidence that people had been assessed to see if this could be considered for them. We looked at the medication administraion records for the people selected for case tracking and these records were all completed in a satisfactory manner. The medication was appropriately and safely stored. We saw evidence that medication audits are undertaken on a regular basis by senior staff members and these did not identify any problems. Practice guidelines have been produced and shared with all trained staff and the medication policy and procedures are available and up to date. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Millwood are protected from potential abuse and harm. There are robust policies and procedures in place that are understood and followed correctly by the staff team. Evidence: The written information provided to us by the unit manager tells us We respond sensitively and rapidly to all events that fall within the framework of Adult Protection and our reporting procedures are adhered to. People who live at the service, their relatives and staff have access to the complaints procedures. Our culture promotes Whistle Blowing and enables people to raise concerns. There is a comprehensive complaints policy and all records of complaints are kept. A monthly summary looks at numbers of complaints, dates and any actions. This information is taken into account to improve the quality of the service provided for people. We have not received any complaints about Millwood since the last key inspection but the service have recorded six. Records showed us that they have all been investigated by the manager and the outcome shared with the complainant. Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: Our surveys asked people Do you know who to speak to if you are not happy?. Six people replied and all said Yes. The relatives surveys asked Do you know how to make a complaint if you need to?. Three replied Yes and one replied No. We spoke with people living at the service and all were aware of how to complain and said they felt confident to do so. Relatives we spoke with also said they would not hesitate to complain if they had any concerns and felt sure they would be listened to and the problem resolved. In the past if I have ever needed to complain, I have been listened to and any problems immediately sorted out. Staff we spoke with demonstrated their knowledge and understanding of Safeguarding Adults and Whistle Blowing. Safeguarding Adults is a process of identifying and reporting suspected or potential abuse of vulnerable people and provides a framework of consistency to protect those individuals at risk. Whistle Blowing is a means for staff to feel supported to report anything of concern that they may witness. One staff member told us People are safeguarded. I Would feel ok to report anything of concern under Whistle Blowing or Safeguarding. Another staff member said The staff are all dedicated to their work and are committed to making sure residents are safe and well. We looked at the records of monies of the people chosen for case tracking and found these all to be correct with receipts for any expenditure and all entries signed. Care Homes for Adults (18-65 years) Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that is appropriate to the needs of the people living at the service and it is well maintained. Evidence: The unit manager told us in the written information he provided The environment is kept clean, tidy and odour free. Millwood is a purpose built unit that is designed specifically to meet the needs of the people who live there. We conducted a partial tour of the home and observed it to be clean and odour free. The communal areas were furnished in a comfortable manner. However, some of the decor and furnishings were needing to be upgraded. The bedrooms we saw were decorated in individual styles and people had brought their own belongings into the home, making their rooms a personal space. All the rooms were equipped with audio and visual systems for people to watch television or listen to music. Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: The laundry facilities appeared to be well organised and managed and measures were in place for minimising spread of any infection. People we spoke with told us that they have not had any problems with laundry. All fire safety checks are completed and up to date. Staff we spoke with have all had fire safety training and know about the services evacuation procedures A full time handy person is employed and records are kept of all safety checks including Legionella, etc. We saw the site maintenance reports that told us regular safety audits are carried out and all required testing is valid and up to date. We looked at the maintenance book and it showed us that any tasks that are identified are recorded by staff for the handyman to see. When the task is completed he signs the book. Staff we spoke with told us that they know how to report any faults or problems and that repairs or replacements take place very quickly. Care Homes for Adults (18-65 years) Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by competent and appropriately trained staff in sufficient numbers to meet their assessed needs. Robust recruitment policies protect people from potential harm and abuse. Evidence: The written information provided to us by the unit manager tells us We ensure that over a 24 hour period all shifts are covered by adequate staff numbers and skill mix. The current ratio is one staff member supporting three people living on the unit, plus staff who are allocated one to one observations. All personal care is delivered by two staff. On the day of the inspection there were fourteen people resident on the unit and the staff numbered thirteen. This did not include activities staff or the unit manager. The manager is always supernumery as are activities co-ordinators. Activities coordinators are employed for a total of sixty hours per week and cover seven days. The night shift currently has seven staff on duty to meet the assessed needs of the poeple living at Millwood. More staff are brought in if the assessed needs of residents Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: require this. The current needs assessment has identified 1152 one to one hours per week. New staff have a 3 month probationary period and at the end of this, they are put forward to undertake National Vocational Qualifications. There is an extensive training programme in place and this includes mandatory training as well as a number of courses that are specific to the skills required for some of the complexities and challenges that occur on the unit. Deprivation of Liberty training is to commence soon. MRSA and infection control policies are in place and training is up to date. People we spoke with told us The staff are good. I like them. Surveys that were returned to us all included positive comments about the staff, They show great care and support to our relative and to us in all areas, no matter how small. They understand my relative and their mood swings. Staff we spoke with told us that they enjoy working at Millwood and feel supported by the unit manager. They confirmed that they undertake a variety of relevant and useful training and access to such is encouraged. Training records that we saw supported this. We looked at the files for three members of staff. All contained references and evidence that the relevant checks had been completed before they commenced their employment. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has an acting manager in post who has made an application to become registered. A unit manager is in place on Millwood and this ensures the health, safety and welfare of people living at the service and of the staff. Evidence: The Annual Quality Assurance Assessment was completed by the unit manager and returned to us within the required timescale. It was completed in a manner that addressed all the key outcome areas and provided us with useful information about the service. This told us We provide robust clinical and operational policies and procedures. All Health and Safety requirements are met and mandatory servicing is completed and up to date. As part of the inspection we looked at the maintenance records. We also looked at the audits that are completed by the manager. These included weekly medication audits Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: and monthly audits of Care Plans and Health and Safety. All were up to date and accurate records. We also saw the outcome of the Annual Quality Survey that is done with the people who live at the service and this told us that peoples opinions are sought and recorded and actions are put in place to address any areas of concern that arise. It also told us that the information is taken into account when any planning and development of the service takes place. As part of our case tracking process we looked at files of three staff members. All had records of supervsions and training. Staff we spoke with told us that they feel supported and listened to by the unit manager Good manager. Strict but fair. You can talk to him. Really approachable and can say anything to him. I know I can ask for help. I feel supported and valued and can count on other staff for support as well. Good place to work, friendly People we spoke with who live on the unit told us I like the manager. He is good and listens to me. If I ask for something, it gets done. Visitors we spoke with also spoke very positively about the unit manager Things are much better now. You can always talk to him and know that he will listen and do what needs to be done. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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