Inspection on 10/10/08 for Queen Elizabeth House

This inspection was carried out on 10th October 2008.

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

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

Other inspections for this house

Queen Elizabeth House 27/10/06

Queen Elizabeth House 20/02/06

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Queen Elizabeth House National Society for Epilepsy Chesham Lane Chalfont St Peter Bucks SL9 0RJ     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Chris Schwarz     Date: 1 3 1 0 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 29 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 29 Information about the care home Name of care home: Address: Queen Elizabeth House Chesham Lane National Society for Epilepsy Chalfont St Peter Bucks SL9 0RJ 01494601300 01494601300 andrew.ferguson@epilepsynse.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Andrew Ferguson Type of registration: Number of places registered: The National Society for Epilepsy care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Date of last inspection Brief description of the care home Queen Elizabeth House is a purpose built home providing care for people who have epilepsy and physical or learning disabilities. It is one of a number of homes on one site at Chalfont St Peter and is managed by the National Society for Epilepsy. There are 12 single en-suite rooms which have been designed to meet the needs of people with disabilities. There are lounges and dining rooms and residents can use the facilities of the site, which include a therapy service and small shop. The village of Chalfont St Peter is a bus or taxi ride away as are the nearest shopping centres. The home is staffed by qualified nurses and carers and residents have the support of a multi disciplinary team including specialist consultant neurologists, psychologists and other therapists. Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 0 12 12 Brief description of the care home Information about the home can be obtained by visiting or telephoning the home. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection was conducted over the course of two days by Chris Schwarz and covered all of the key National Minimum Standards for younger adults. The last key inspection of the service took place in October 2006. Prior to the inspection, a detailed self-assessment questionnaire was sent to the manager for completion and comment cards were sent to a selection of people living at the home, staff and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussion with the manager and other staff, opportunities to meet with people using the service, examination of some of the homes required Care Homes for Adults (18-65 years) Page 6 of 29 records, observation of practice and a tour of the premises. Peoples equality and diversity needs were taken into account throughout. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff working at the service and in the human resources department and people who use the service are thanked for their co-operation and hospitality during this unannounced visit. What the care home does well: What has improved since the last inspection? What they could do better: Care Homes for Adults (18-65 years) Page 8 of 29 The inspection reflected a high quality of care practice at Queen Elizabeth House and an improvement since the last key inspection. Three recommendations have been made to supplement practice: Video versions of peoples care plans should only be produced on computer equipment on site to meet with data protection requirements. Receipts need to be written where individuals deposit money into users accounts to make sure that a record is kept. It would be an additional good practice to ask the person depositing the money to also sign the receipt to verify the details are correct. An explanatory key needs to be added to the staff rota to explain the hours the abbreviations represent. 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 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 10 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 using the service are thoroughly assessed prior to admission and are given opportunity to visit the service beforehand to ensure it meets their needs. Evidence: A service users guide was in place at the service providing prospective users with a good range of information and what they may expect of the service. Photographs had been used to make it more eye catching and to give people a good feel of the place. Different versions of the guide could be made available to people upon request if required. There had been three new admissions since the last inspection of the service. The files of two of these people were looked at to see what information had been obtained about their care needs. For each person there was an application form and an admission assessment. Essential information such as name, preferred form of address, date of birth, gender, religion, next of kin and cultural needs had been noted. Peoples personal and health care requirements had been recorded and there were Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: accompanying assessments such as an epilepsy needs assessment. Information that was looked at showed that peoples needs had been ascertained in detail before they moved in and that people had been appropriately placed at the service. Anyone being considered for a placement at the service would be invited to visit for informal and tea visits before a longer assessment period of around 6 to 8 weeks. Fees for the service were approximately two thousand one hundred and ninety pounds per week with extra costs for additional identified support. Care Homes for Adults (18-65 years) Page 12 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. There is good regard for the diverse needs of the people using the service and their requirements related to their disabilities, lifestyle choices and personal preferences are sought, recorded and met by the staff team, respecting their rights, choices and individuality. Evidence: Care plans were in place for each person using the service. A useful quick reference guide had been set up in each of the files examined, outlining information such as peoples communication needs, physical needs and equipment needed, assistance needed with personal care, medication requirements, epilepsy precautions, their personal timetables and religious, gender and cultural needs. Each file identified the persons keyworker and named nurse and set out arrangements for purchasing toiletries, clothing, presents for anniversaries, arranging holidays and managing finances. Care plans were divided into sections with support plans for areas such as communication, personal hygiene, eating and drinking, moving and handling, Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: elimination, maintaining safety and social activity. Peoples preferred form of address, gender, religion, cultural needs and other personal information had been noted. Risk assessments were in place for areas such as bathing and showering, likelihood of developing pressure damage, moving and handling and nutrition. Accompanying guidelines were in place where individual risks were noted, such as sleep apnoea and assaults on staff. Consent forms were seen for managing medication, entering bedrooms and preferred gender of staff providing assistance, signed by next of kin if the person was unable to do this. All records were dated and signed and contained evidence of regular review to make sure that information was current. Notes of review meetings were also contained on peoples files. One person who completed a survey form said person centred individualised care was good. Work had also taken place to make peoples care plans accessible to them. Four video care plans had been introduced at the service; two people have said they do not want one of these and their wishes are being respected. Work is expected to take place over the coming eighteen months to produce the remaining ones. Two of the videos were looked at. Both provided unique perspectives of peoples care; one involving the persons next of kin to relate background information and useful footage of the techniques the keyworker and other staff use to carry out personal care and help manage challenging behaviour. The other video contained the user himself speaking about what was important to him and areas such as positioning for various moving and handling manoeuvres were covered. Editing of the video footage was being done on one of the staffs computers at home which has implications for data protection. It is recommended that only equipment on site is used for production of the care plans, to make sure that privacy and confidentiality are fully upheld. Peoples money was being managed using the on site banking facilities. The service was keeping a float of money for day to day expenditure, with individual transaction sheets and receipts retained to verify expenditure. No receipts were being written where relatives deposit money into the house accounts and a recommendation is made to address this. There are various forums which people using the service can make use of to contribute to decision making and give feedback on their care. Minutes of parents and friends meetings and service users meetings were seen as well as the site-wide service users committee meetings. There is also access to advocacy services. Care Homes for Adults (18-65 years) Page 14 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. Activities are available to people using the service to provide them with stimulation and contact with family, friends and the community is supported to maintain social links. Food is well prepared and presented attractively to make sure that nutritional needs are met and respecting peoples preferences and religious or cultural requirements. Evidence: The service has an activities co-ordinator and each person has an activity plan in place. Records were being kept of the social activities that people take part in (as well as occasions where opportunities are offered but declined). These included music sessions, using the internet café with staff support, communication sessions, art, accessing the library, swimming, rebound therapy, sensory therapy, attending colleges, attending a harvest festival service, involvement in meal preparation with Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: staff and passive movements. People also enjoy going to the cinema, eating out and one person has been involved in a drama group. One person worked in the shop on site during the morning of one of the days of the inspection and was also looking forward to going away on holiday to France for a week with staff. Visitors were observed to be free to see service users during both days of the inspection. Routines within the home were flexible with people using the service getting up at different times and choosing where to have their meals. Staff were seen knocking on peoples doors before entering bedrooms and using preferred forms of address. Those who wished to be in their rooms alone were free to do so. All the meals are prepared in the service using a 28 day menu. A varied diet was being offered to people using the service with service users encouraged to assist in meal preparation. Advice from the dietician had been sought in one care plan file that was looked at Some of the people who completed surveys said food was good and they indicated they can do as they wish during the day, the evenings and at weekends. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people living at the service are well met, promoting health, well-being, taking into account their preferences and religious or cultural requirements and ensuring that they receive medication in a safe and consistent manner. Evidence: Peoples care plans provide comprehensive details of the support they require and have been kept up to date with regular reviewing. Bathroom and bedroom doors were kept shut whilst staff provided people with assistance and one persons dignity was safeguarded whilst having a seizure in the dining room through staff closing curtains and preventing anyone coming into the room. Care plans reflected peoples wishes for gender of staff providing support and the building was equipped with a wide range of equipment to assist people in daily living tasks such as ceiling tracking, adjustable beds, scales suitable for people who use wheelchairs and adapted baths and showers. Records on peoples files showed involvement of a range of health care professionals such as physiotherapists, dieticians, the consultant neurologist, consultant psychiatrist and psychologist. Records of peoples weight were being maintained and a range of Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: assessments was in place to manage health effectively, such as nutritional and pressure risk indicators. A detailed support plan was seen in one persons file that had been prepared by the psychologist to help manage behaviour. Each file that was examined had a recent neurology review in place and/or a joint psychiatric and neurology review. Feedback from the consultant neurologist about standards of care was positive, as was the feedback from one of the doctors visiting the home during the inspection. Staff were observed to respond to ill health promptly and appropriately. Medication was being managed effectively. Each person has a cabinet in their bedroom. Storage for controlled drugs and other items is within a separate treatment room. There is a pharmacy on site. Medication administration records were looked at for a sample of people using the service and these were generally up to date. The manager was advised to be cautious where one person had received medication later than other users as the record sheet had not been signed in a timely manner by the person administering medication. Medication records contained a photograph of users for easy identification and their known allergies and sensitivities were recorded. A protocol was in place where one person requires their medication to be given covertly and this had been agreed by the consultant neurologist and psychiatrist. A protocol for use of as required medication was also agreed by consultants and other interested parties and was updated promptly by staff when advised to do so. A complaint regarding providing support to people who are admitted to hospital has resulted in a protocol being put in place to manage this better. 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. Complaints and adult protection are generally managed well to listen to views of people who use the service and their representatives and reducing the risk of harm to people. Evidence: The Commission was aware through information provided in the pre-inspection selfassessment and from contact with relatives and other parties that some complaints and safeguarding issues have arisen since the last inspection. These included missing money, access to users money, support of users whilst in hospital and a complaint by a member of staff about a comment made by a relative. One recent complaint had taken a while to respond to by senior management due to a misunderstanding, others had been dealt with in good time. Where complaints also contained an element of safeguarding, the appropriate outside agencies such as the police, Commission for Social Care Inspection and Social Services Department had been contacted. Procedures for making complaints and responding to safeguarding incidents were in place. A copy of an easy read complaints procedure was located on notice boards around the building. Staff training records showed that they receive training on safeguarding vulnerable adults. Each care plan file that was examined contained a record sheet for any injuries or body marks that staff observe whilst carrying out personal care. Where one person had a Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: physical intervention plan it was clear in stating that intervention should be as a last resort only and carried out by staff trained to do so. The plan had been agreed by appropriate parties including the user and consultants involved in her care and had been signed, dated and recently reviewed. Records of restraint were noted - there had been four occasions in the past year. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is clean, well decorated and adequately maintained, promoting a positive environment for the people who live there and which is suitable for the range of disabilities that people have. Evidence: Queen Elizabeth House is sign posted on site and has parking close by for visitors and staff. The building is purpose designed on ground floor level and provides accommodation in spacious single en-suite bedrooms. There are two lounges and dining areas, one of which visitors may use to make themselves drinks and snacks when they visit. Doorways and corridors are wide enough to easily accommodate people who use wheelchairs and equipment has been provided throughout to meet peoples needs. Bedrooms have been arranged and personalised to different tastes and each had plenty of natural light and a patio door leading to garden areas. Decor was in good condition throughout. Bathrooms were suitable for the needs of people using the service and were spacious enough for safe manoeuvrability of wheelchairs and hoisting equipment. There are several large walk in cupboards around the building for storage of supplies. There was good regard for infection control measures through use of colour coded mops and buckets, provision of protective items and safe disposal of clinical waste. The building is fitted with a nurse call system. There were no unpleasant Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: odours around the building. 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. The service provides staff cover to meet needs and undertakes thorough recruitment procedures, coupled with effective training, to ensure staff have the right skills and competencies to support the people who live there. Evidence: The service is staffed according to the high needs of people living at Queen Elizabeth House with nine or ten staff generally on duty each morning, nine covering the afternoon/evening shift and four on waking night shift. At least two staff on each shift are qualified nurses. Rotas are maintained of cover at the home. Abbreviations are used as short hand for the range of shifts at the home - it is recommended that a key is added to the page to explain the hours these relate to so that it is clear who was in the building at any given time. A gallery of staff photographs and their names was located in the entrance hall. The manager said there were 11.5 staff vacancies at the service. Staff cover has been maintained without needing to resort to agency use. This had been achieved through staff working voluntary overtime up to a maximum limit per week set by the human resources department and through use of bank/relief staff who work around the site. The manager said it has been possible to retain the same bank workers to provide Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: consistency and continuity for people using the service. The senior on duty was observed effectively arranging cover on one of the days of the inspection to make sure the service was properly covered. The manager facilitated access to recruitment files in the human resources department. Six files of people who had started since the last inspection were looked at. Each contained satisfactory Criminal Records Bureau clearance, an application form, two written references, verification of personal identification number (for qualified nurses), proof of identification and information from the borders and immigration department where necessary. A query regarding one persons immigration details was responded to promptly. Staff were observed to be respectful and polite to people using the service and safeguarded their dignity. On both days of inspection the atmosphere within the service was calm and staff carried out their duties without rushing. Three handovers take place across the 24 hour day. The handover from morning to afternoon shift was observed and involved a résumé of each persons well being. Tasks were allocated such as who would be administering medication and preparing the evening meal and times for taking breaks were agreed to provide continuous nurse coverage. Training records of six staff and the manager were looked at. Mandatory training was generally well covered (missing evidence that one person had up to date moving and handling training was mentioned to the manager to follow up) and specialist courses had also been attended such as venepuncture and cannulation, epilepsy awareness, personalising care plans, safe behaviour management, autism spectrum disorder and PEG feeding. The manager had kept his training up to date and had been on courses such as a two day exploring challenging behaviour and related issues course, master class in epilepsy, a mentoring update and a leadership and management course. Staff meetings take place on a regular basis - there were records of five meetings so far this calendar year. Minutes showed that staff were being reminded of good practice during meetings and had been invited to contribute towards information that was used in the pre-inspection self-assessment and to be able to facilitate the inspection if the manager was not on duty. 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 management and administration of the home promotes continuity and quality of care for the people who live there and ensures that risk is safely managed to reduce the likelihood of injury or harm. Evidence: The manager works full time and is a registered nurse. He is registered with the Commission and has achieved the Registered Managers Award. He has experience of working with the service user group and has worked at the National Society for Epilepsy for a number of years. The pre-inspection self-assessment had been completed to a good standard and was submitted in time to assist with the inspection planning. Deputy manager arrangements are in place to provide an additional tier of support at the service. Records within the home showed that the manager is actively involved in the running and development of the service and has systems in place to audit practice to make sure it meets acceptable standards. Monitoring also takes place by the board of Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: governors who visit each month to evaluate standards of care. A medication audit had taken place earlier in the year and there had been a health and safety audit last September. Following an allegation of missing money from the service, external auditors had been brought in to evaluate financial management in September this year. A quality assurance exercise had taken place recently with surveys sent out to relatives, staff, visitors and bank workers and the findings were due to be collated into a report. The certificate of registration was displayed in the hallway. There was current employers liability insurance in place and a copy of the recent annual service review report was displayed plus the complaints procedure and minutes of the service users committee meeting. A range of health and safety checks was in place at the service. A current gas safety certificate was in place, portable electrical appliances had been checked recently, certificates were in place to show that hoisting equipment had been serviced and fire fighting equipment was being maintained. The water supply had been analysed for Legionella species and remedial measures had been put in place until traces of bacteria had been eliminated (achieved in October this year). 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 1 6 Video versions of peoples care plans are only to be produced on computer equipment on site, to meet with data protection requirements. Receipts are to be written where people deposit money into users accounts to make sure that a record is kept. It would be an additional good practice to ask the person depositing the money to also sign the receipt to verify the details are correct. An explanatory key is to be added to the staff rota to explain the hours the abbreviations represent. 2 7 3 33 Care Homes for Adults (18-65 years) Page 28 of 29 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. 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. Care Homes for Adults (18-65 years) Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!