Inspection on 17/02/09 for Shamrock House

This inspection was carried out on 17th February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shamrock House 11/12/07

Shamrock House 22/08/06

Shamrock House 06/12/05

Shamrock House 05/07/05

Shamrock House 26/10/04

Shamrock House 20/05/04

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: Shamrock House 69 Hook Road Goole East Yorkshire DN14 5JN     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: Janet Lamb     Date: 1 7 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 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 31 Information about the care home Name of care home: Address: Shamrock House 69 Hook Road Goole East Yorkshire DN14 5JN 01405766217 F/P01405766217 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Lila Chaudhary Name of registered manager (if applicable) Mrs Marcia Dorothy Nicholls Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 17 The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Mental disorder excluding learning disability or dementia: Code MD, maximum number of places: 17 Date of last inspection Brief description of the care home Shamrock House is a care home that is registered to provide accommodation and care services for up to seventeen people who have mental health needs. Bedroom accommodation is in five shared rooms and seven single rooms and there is a new lounge and new ground floor bathroom and shower facility, as a result of an extension completed in the last two years. People have the opportunity to mix in the communal areas, which currently consists of two lounges and a dining room. The garden area is accessible to wheelchair users, and although the homes two original bathrooms are Care Homes for Adults (18-65 years) Page 4 of 31 care home 17 Over 65 0 17 Brief description of the care home situated upstairs those with mobility problems now have access to the ground floor facilities. The location of the home close to the centre of Goole, ensures that there is good access to bus and train services for both people living at the home and their visitors. Current information about the care and services provided at Shamrock House in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection (CSCI), now the Care Quality Commission (CQC) are available by contacting the home. The fees, according to information from the home at the time of the site visit, range from £297.80 to £470.00 per week and do not include costs for hairdressing, chiropody, toiletries and activities. Care Homes for Adults (18-65 years) Page 5 of 31 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 key inspection of Shamrock House took place over a period of time and involved the sending of an annual quality assurance assessment (AQAA) form to the home in October 2008 to complete. This was returned to us in December 2008 and contained information about the service, data about the people living there and staff working in the home, as well as information on the homes practices. We then sent surveys to people and staff in the home asking them what they thought about living and working there. All of this, along with information sent to us in notifications, or brought to our attention by placing authorities, was then considered to determine what it must be like living in the home. Then on 17/02/09 Janet Lamb carried out a site visit to test whether or not Care Homes for Adults (18-65 years) Page 6 of 31 the information and views of life in the home were correct. People living in the home were interviewed or spoken to about their lives and the support they receive, staff were asked about their experiences of being recruited and trained and how well a service they considered they provided, and the manager was interviewed about practices and systems. Some of the communal areas and private areas were viewed with permission from people, and observations of interactions between people and people and staff were also used. This report was then produced showing how all standards were assessed and judged. 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 31 The service could make sure the statement of purpose and service user guide contain everything listed in schedule one of the regulations for this category of service. It could make sure people are able to keep their belongings safe and secure by offering them a key to their room. The service could make sure staff giving out medication have annual competence assessments carried out. It could make sure staff sign the record of fire safety training drill as evidence of their presence. All of these are so people living in the home are confident their needs are being met safely and competently and their privacy is being maintained. 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 9 of 31 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 31 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 satisfactorily assessed and receive sufficient information about the home before they decide to move in, so they are confident their needs are met. Evidence: Discussion with people in the home, the provider and the manager, and viewing of case files and records with peoples permission reveals there are good opportunities to test drive the home and view information before a person decides to move in. There is now a new statement of purpose and service user guide for prospective people wishing to move into the home, to consider. These documents are held in peoples files and some are signed to show they have been seen. They have information that meets the requirements of regulation 4 and 5 of the Care Homes for Younger Adults and Adult Placements National Minimum Standards, Care Homes Regulations, but the manager should make sure all of the information listed in schedule 1 is available. Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: People spoken to say they were part of the assessment process and found the visit from the manager very useful. Two people say in surveys they did not receive enough information, but this was due to an emergency admission for one and a second admission to the home for another. Documents in files also back up and evidence the systems for assessing people. There are placing authority and the homes documents available for viewing. Care Homes for Adults (18-65 years) Page 12 of 31 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 have their individual needs and choices well recorded in care plans and other documents show how needs are met. People enjoy a good level of decision making and staff help them to maintain a safe lifestyle with the implementation of risk management strategies and practices. Evidence: Discussion with people in the home, the manager and staff and viewing of case files and documents with peoples permission shows there are improved systems for recording and meting peoples needs, while encouraging them to make decisions within appropriate risk management strategies. People now have improved care plans to record and monitor how their needs are met. Care plans include at least 12 areas of need that cover such as personal hygiene, mobility, mental and physical health and social contact and finances to name a few. Plans are more person centred and include people in the compilation of them. People Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: sign documents in agreement to them being carried out wherever possible. People say they are aware of care plans being in place, know when they are being reviewed, and feel more included in making decisions about their care. People also say they are included in reviews of their care and can invite significant others to them. Evidence of reviews held is available in case files in the form of review minutes and records. People say they can make decisions about what they do, when and where, and who they see etc. People are encouraged to be independent and to make decisions where possible on everything. Most of them receive their weekly personal allowance though some have it metered out to prevent it being spent all at once, and are therefore mostly in charge of their finances. People are generally quite satisfied with the arrangements in place. There is sometimes an element of risk involved when people decide for themselves what they want to do and when etc., but these risks are reduced where possible with the use of risk management systems and strategies in place, and with advice and encouragement from staff. Documents are satisfactorily maintained and kept up to date. People are aware of risk assessments and sometimes the restrictions placed on them, and people are generally understanding of the need to curb some behaviours. People are also aware of the consequences they may have to face if they choose to go against prior agreements. Generally people are able to live their own lives and have reduced risk where it is possible to do so. Evidence is available in case files in the form of risk assessments, recordings of daily activities, specific agreements and records of such as weight, intake, GP visits, health etc. Care Homes for Adults (18-65 years) Page 14 of 31 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 enjoy good independent lifestyles of their choosing, see family and friends when it suits them, and make routines of their own. Daily living and food provision are satisfactory and of peoples choosing and are underpinned by good systems for managing risks and promoting fulfilling, independent lifestyles. Evidence: Discussion with people in the home, the manager and staff and viewing of some document in case files with permission, and some records held in the home, shows there are satisfactory arrangements to enable people to lead relatively satisfactory lifestyles of their choosing. There is an activity plan in the home showing what people can do that is organised. It includes reflexology, card making, quiz, baking and learning to budget. People occupy Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: themselves through the day time with adult education courses, or if able to obtain them, part time jobs. Mostly people tend to watch television, listen to music, read newspapers or books, take walks out or go to local cafes etc. The local health centre has been popular in the past but people are unhappy that it is currently closed. The females in the home like to go shopping for either food for the home or more especially for clothes and make-up. Some people may go swimming at Goole leisure centre, which is very close by and in walking distance, though enjoyment of this depends on peoples circumstances. One person is unable to go because of health and another person just refuses completely. A third person is waiting for a relative to make arrangements for him to go see some local football team in action. Some people like to help out at the Sobriety Project, which is a charity project that runs from the canal in Goole and offers people trips on barges, boats and sailing craft. There are things to do in-house, such as board games, darts, dominoes etc., but the staff say it is difficult to get people motivated some times. There is also a karaoke machine, which staff want to be used more often and plan on organising more social evenings for this purpose. Two people were observed playing cards on the afternoon of the site visit. One person says she would like to get out more, but has mobility problems and finds it very difficult. Staff do try to motivate people into improving their physical health as well as their mental health, in order to have more opportunities available, but the task is not always easy for staff or the people needing motivation. People say they have opportunities to vote when polling comes around and that they join in with other community activities wherever possible. Staff say they give up of their own time sometimes to take people out in the evening or at weekends and understand this is a part of their role as carers. Staff accompany people on holiday and last year two small groups of three and two went to Turkey, assisted by staff. Two people went to Butlins and one went on holiday with family to Skegness. People are encouraged to make friends and to have meaningful relationships and two people do spend a lot of time together as partners. People see family members when they can and when family members are receptive, though people say they wish this was more often. There are no concerns about restrictions on seeing people, in fact the home very much welcomes family and friends. There are very few routines within the home and mostly around meal times, drink times and attending appointments. The only other routines are the ones people make for themselves, individually and personally and because of their need to maintain consistency and to avoid change. People use their rooms little in the day time except for a nap. Three people did this on the day of the site visit. One person says although Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: it was requested at the last inspection, a key to his room, so he can lock his possessions up when out, has still not been supplied. This was a requirement of the last inspection under standard 24, but is being made a new requirement in this report under standard 16. There are no adverse comments about food provision, either in surveys or in interviews. People spoken to say they do not really have a say in the compiling of menus, as the cook and manager decide on what goes on the menu. People do make comments on their likes though and this information is taken on board when making changes. People say they enjoy the food, are able to find out what is on offer from the menu on display and are usually very satisfied with the amounts and options for more. Observation of the lunch time meal shows everyone ate heartily. Seating arrangements are flexible, though some people follow routines of their own. There is a choice of eating in the main dining room or in the lounge/dining room. All needs appear to be catered for. Special diets and weight reducing diets etc. are available though people make their own choices. Care Homes for Adults (18-65 years) Page 17 of 31 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 good levels of personal and healthcare support and are benefiting from robust systems and safe practices for handling medication. Evidence: Discussion with people in the home, the provider, manager and staff, viewing of some documents and records with peoples permission, and observing some of the practices shows there are satisfactory arrangements and systems in place for providing personal and healthcare support. There are personal and health care support plans in place, which are combined with the care plans. They cover physical health needs as well as mental health needs and they have records and charts that show what specialist support and advice is offered and given. There are also records kept for showing staff support and action to help people maintain good health on a daily basis. Diary notes are split into eight sections that include general health, personal hygiene, medication, food and drink, social activities, family contact, sleep pattern and miscellaneous. The miscellaneous section includes GP and CPN visits, any injections or other treatment given etc. There is a Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: diary entry for each person three times a day. The home also holds a personal folder in the office for each person in the home, which contains their passport, insurance papers and personal documents etc. All specialist health care treatment and support is provided by external professionals, but is still recorded in the home by staff. All health care needs are combined within care plans and the whole care package includes physical and mental health needs and action plans. Medication handling and administration practice is underpinned by following policy and procedure and by ensuring staff giving it out are properly trained and competence assessed. Staff say they are trained in handling medicines having done the Boots Chemist training course. Two staff files seen with their permission shows their medication training was done on 24/07/07. Where staff give out medication they should have annual mandatory medication competence training. This is therefore a recommendation of this report. Medicines are stored in a locked cupboard within the home. The Boots monitored dosage system is used and manrex cards are removed from the cupboard and taken to the lounge or dining room, where people are expected to take responsibility for their medication and present themselves at the required time to take it. Two staff supervise the giving of medicines, one to remove them from the manrex card and put them into a plastic pot and the other to sign to say they have been taken. Controlled drugs are double signed in a controlled drug register after being witnessed, though no one is taking any of these at the moment. All medicines administered are recorded when given on medication administration record (MAR) sheets. MAR sheets seen appear to be satisfactorily completed. People spoken to say they are happy with the arrangements for their medicines to be held and administered by the home as they would not like the responsibility to look after it and would probably forget to take it at the right times. Care Homes for Adults (18-65 years) Page 19 of 31 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 have good systems in place to enable them to complain and have their complaints effectively resolved. There are good systems in place for making and referring allegations of or actual abuse to the appropriate authorities and most of the staff are trained in safeguarding procedures, so people are confident they are protected from the risk of harm. Evidence: Discussion with people in the home, the provider, manager and staff, and viewing of some of the records in place, shows there are satisfactory arrangements in place to enable people to speak up if they are dissatisfied and to ensure people are protected from the risk of harm or abuse. There is a complaint policy and procedure in place and people are given a copy on moving into the home. There is also a file for recording complaints, but none have been received for some time now, as the manager has over the years encouraged people to speak to her when they have any dissatisfaction. Her openness and willingness to achieve satisfaction has lead people to trust the system and they are confident they will be listened to and have their complaints resolved effectively. People say they know they have the right to contact their placing local authority, should the home not be able to satisfy their complaint. Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: Staff understand that people are not always completely satisfied with the service or sometimes make complaints about each other, and they are fully aware of the procedure to follow. There is a complaint book to record issues in and a suggestion box in the hallway in which forms can be anonymously put. Only the provider has access to this suggestion box. There is a policy and procedure on safeguarding adults coordinated and provided by the Hull and East Riding of Yorkshire Safeguarding Adults Board. The manager has completed safeguarding training and all staff have completed protection of vulnerable adults training at the local hospital in September and October 2008. Discussion with staff shows they appear to fully understand safeguarding issues and how to report them, through the manager or directly to social services if necessary. The outcome for people is that they have good systems in place for staff to listen to them and refer issues. There is a safeguarding record that shows no entries for the last twelve months. People have their finances appropriately protected as well because there are monitoring and recording systems in place for handling finances. Where people are not able to control their finances they have family members that do so or the home maintains systems for them. Most people have some money held in safe keeping, which is metered out appropriately as they would spend all their funds in one go. One has a brother that controls his finances, another had intervention from the social services department to ensure money was attributed fairly and properly. There may be several arrangements in use for individuals, but no one expressed any desire to change any of them. One person was observed receiving his daily allowance from one of the staff and it was done carefully and sensitively to ensure accuracy and to maintain dignity. Records were completed and the person signed. Care Homes for Adults (18-65 years) Page 21 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is well suited to its stated purpose, that meets their environmental needs well, and is safe, clean and comfortable. Evidence: Discussion with people in the home, the provider, manager and staff and viewing of some of the private areas and all communal areas of the home, shows the environment has improved over the last few years. There is a new extension to the home, which contains five single ground floor bedrooms, a lounge/dining room, a laundry and a shower room. The alterations have also resulted in the kitchen being made smaller, although it has been newly fitted out with equipment. There is also an external lean-to in the garden where people are able to smoke. The home is more suitable to its stated purpose of providing care, support and accommodation to people with mental health needs. Requirements and recommendations made at the last inspection have been dealt with under the homes action plan and are almost completed. The provider and manager are well aware of what still needs to be done. One of the requirements was under standard 26, to produce written risk assessment documents for where bed safety rails are in use. All safety rails have been removed from the home and the only person needing such Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: equipment now has a specialist bed with integral safety sides. The home is observed to be clean and comfortable and free from any odours. There is a new laundry within the extension and it is fitted with new machinery etc., so the Water Supply (Water Fittings) Regulations 1999 are being met. There is suitable hand washing facilities in the laundry for staff to use and staff say they have been trained in infection control. This is evidenced in staff training files, and shows some staff completed training in 2005 and 2007. The manager needs to check staff are up-todate with their infection control training and if necessary ensure they complete it again. Care Homes for Adults (18-65 years) Page 23 of 31 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. Staff are satisfactorily recruited and selected, are given good opportunities to become qualified and trained in their roles, and work in satisfactory numbers to meet the needs of people in the home. Evidence: Discussion with the provider, manager and staff and viewing of staff files and some records with permission, shows there are adequate systems in place to ensure staffing issues are appropriately dealt with. Staff say they completed a full recruitment process to obtain the job and that they have satisfactory opportunities to do qualifications and training. Staff files back up their information and evidence is available of inductions completed, Skills for Care mandatory training in fire safety, moving and handling, medication administration, health and safety, first aid, and safeguarding adults undertaken and NVQ courses enrolled for or completed. There is evidence in the form of rosters and from discussion with people who say their needs are met, to show sufficient staffing is available throughout the day and night to meet peoples needs well enough. On duty on the day of the site visit was the Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: manager, two care staff, one cleaner and a cook. The provider was also working in the home. People say there are enough staff on duty, they are approachable and helpful. Care Homes for Adults (18-65 years) Page 25 of 31 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 manager runs the home in the best interests of the people that live there, to ensure the conduct and management of the home is good. People have their health, safety and welfare well promoted and protected. Evidence: Discussion with people in the home, the provider, manager and staff and viewing of some records and documents in relation to health and safety matters, shows there are satisfactory arrangements in place to ensure the conduct and management of the home is satisfactory. The manager has been registered some years now, has completed NVQ level 3 in Care and almost completed NVQ level 4 Registered Managers Award. However because the deputy manager is now doing this course and in view of the fact that the manager does not wish to complete, it is acceptable that one of them does complete. They jointly and effectively manage the home at the moment and should probably continue this for years to come. As a team they are well liked and respected by people in the Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: home and staff. There is a satisfactory quality assurance system in place, which utilises surveys, weekly audits on the home environment and a summary report to be delivered to East Riding of Yorkshire Council quality development scheme. There are also reviews of peoples care, house meetings and informal discussions as well as the opportunity to make complaints, that inform the quality assurance system. Regulation 26 visits are now made to the home and the provider compiles a brief report. Several areas were sampled to determine that health, safety and welfare of people and staff is promoted and protected. All outstanding requirements and recommendations made in this section at the last inspection have now been met. Water outlets are now checked for excessive heat and records maintained and some staff have completed a first aid course. A portable appliance test was evidenced as being done on 18/12/08. Fire safety systems are well maintained and both maintenance of the detection systems and training of staff are up to date. It is recommended that staff sign the fire safety training drill themselves to evidence they were present. Satisfactory areas are the gas safety certificate is current, a legionella water test certificate is current and staff fire safety training is good. Extinguishers have been maintained within the last twelve months. Sufficient has been seen to determine the provider, manager and deputy are running the home sufficiently well enough. Care Homes for Adults (18-65 years) Page 27 of 31 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 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 12 The registered provider must enable people to keep their room and belongings safe and secure, by offering them a key to their room. So people are confident their possessions and belongings are safe and secure when they are out of their room. 29/05/2009 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 1 The registered provider and manager should make sure the new statement of purpose and service user guide contain all of the information listed in schedule 1, so people are confident they are fully informed of the service on offer. The registered provider should make sure staff giving out medication receive annual competence assessment, so people are confident their medicines are handled safely and according to the Medicines Act 1968 and the Misuse of Drugs Act 1971, and the guidelines of The Royal Pharmaceutical Society. The registered provider should make sure staff sign the Page 29 of 31 2 20 3 42 Care Homes for Adults (18-65 years) record of fire safety drill as evidence of their presence, so people are confident they are protected form the risk of harm from fire. Care Homes for Adults (18-65 years) Page 30 of 31 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. 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. 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