Inspection on 30/03/09 for The Manor House Residential Home

This inspection was carried out on 30th March 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Manor House Residential Home 06/02/08

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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: The Manor House Residential Home 137 Manor Road Littleover Derby DE23 6BU     The quality rating for this care home is:   one star adequate 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: Claire Williams     Date: 3 0 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 32 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 32 Information about the care home Name of care home: Address: The Manor House Residential Home 137 Manor Road Littleover Derby DE23 6BU 01332372358 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): the_manor_house@hotmail.co.uk The Manor House Residential Home Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 11 Number of places (if applicable): Under 65 Over 65 0 0 learning disability sensory impairment Additional conditions: 11 11 The maximum number of service users who can be accommodated is: 11. The provider may provide the following category of service only: Care Home - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD Sensory Impairment - Code SI. Date of last inspection Brief description of the care home The Manor House was registered on 30th October 2007. The building used to be a domestic dwelling that has been renovated and extended to meet the requirements of a residential care home. The home is registered to provide personal care and accommodation for eleven people of either sex aged 18 and over with sensory impairment and learning disabilities. Care Homes for Adults (18-65 years) Page 4 of 32 Brief description of the care home The physical environment of the home includes 8 single bedrooms on the ground floor and 3 large bedrooms on the first floor. Access to the first floor is by stairs only. All rooms have en-suite facilities, and emergency call systems. The home has a sensory room, which is located on the ground floor in the conservatory. There is an accessible landscaped garden and patio areas. In addition to the en-suite facilities there is a communal bathroom with a jet spa bath equipped with an electronic ceiling hoist. The service provides people with a combined Statement of purpose and Service user guide. Information provided by the service stated that the current fees ranged from 650 to 950 pounds per week . Information is provided in the Statement of purpose/Service user guide of the services that are included in these fees. Care Homes for Adults (18-65 years) Page 5 of 32 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: one star adequate 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 quality rating for the service is One Star. This means the people who use the service experience adequate quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice: and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of a day. In order to prepare for this visit we looked at all of the information that we have received since Care Homes for Adults (18-65 years) Page 6 of 32 our last visit which was undertaken on 06/02/08. This includes: What the service has told us about things that have happened in the service, these are called Notifications and are a legal requirement. The annual quality assurance assessment (AQAA). This is a self- assessment that focuses on how well outcomes are being met for people using this service. The AQAA we received was completed in brief detail. Surveys- we sent these to people who use the service, their relatives and to the staff and professionals in order to obtain their feedback. We received, 5 from people who live in the service (these had been completed with support from the staff team) 6 from the staff team, 2 from Care managers and 3 from peoples relatives. Comments have been included in the report. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of two peoples files representing a cross section of the care needs of individuals that use this service. Discussions were held with those individuals as able, and observations were made of the interactions between the staff and people. Individuals care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for peoples care and also for staffs recruitment, induction, deployment, training and supervision. What the care home does well: What has improved since the last inspection? What they could do better: We have made 5 requirements following our visit these include: For people to have a care plan completed after they have moved into the service, which is kept under review, so staff know how to meet their needs. For risk assessments to be completed after people have been moved in so that any health care needs can be identified and monitored. For the recruitment practices to be improved so that all of the required information is obtained, for new employees. This includes full employment history, contracts, and job descriptions. This is to ensure that new staff are suitable to work in this service. For staff to receive regular supervision to support them in their role. For quality assurance systems to be implemented in order to obtain feedback from people who are involved with the service. This is to ensure a quality service is provided Care Homes for Adults (18-65 years) Page 8 of 32 at all times. Some recommendations have been made and if implemented this will enhance the service received by people who live here. 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 32 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 32 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 sufficient information about the service in order for them, and their relatives, to make an informed decision about whether the service is right for them. Evidence: In the annual quality assurance questionnaire completed by the service, they told us they ensure a comprehensive approach to peoples admission to the home, in terms of visits and information provided. At this inspection we saw that the combined statement of purpose and service user guide was in place in a written format. This document does not reflect the change in management and therefore does not provide people with updated information about the service. We looked at two files for people who had recently moved into the service. Records for both people demonstrated that a pre- admission assessment had been undertaken Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: before these individuals started using the service. As part of the transitional process people, their families/ representatives are encouraged to visit the service. This enables them to familiarize themselves with the building and the staff, and to make an informed decision about using the service. Care Homes for Adults (18-65 years) Page 12 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples change in needs and goals are not reflected in a person support plan, this has the potential to compromise the support they receive. Evidence: In the annual quality assurance questionnaire completed by the service, they told us all people had comprehensive plans in place which were supported by risk assessments. In the two files we sampled only one file contained a support plan that had been completed by this service. The plan was person centred but was out of date. It had not been updated to reflect the deterioration in the persons needs. The second file contained a transition care plan which had been completed by the staff at the persons previous placement. A care plan had not been completed following this persons admission and they have lived in this service for several months. This means the staff team do not have access to updated written information to direct them on how to Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: support these peoples needs. However when we spoke with the staff on duty and observed their practice, they were able to demonstrate their knowledge of these individuals and their needs. Staff told us they did not actively contribute to the completion of care plans and therefore they had a hands on approach to providing peoples support. The feedback from the staff surveys also supported this. Daily records are completed to ensure good communication between the staff regarding each person, and any change in need was clearly recorded within these. After we identified this shortfall a care plan was completed following our visit within 24 hours. Both individuals have limited verbal communication and there was no communication aids or updated information to direct staff on their preferred communication style. The staff members told us they respond to peoples facial expressions in order to enable the person to make choices and have some independence in their life. A range of risk assessments had been completed and these mainly focused on keeping people safe. People we spoke to told us the following about the service: I like living here it is good and the staff support me the way I want them to The staff are nice and help me with things I cannot do myself. Feedback provided in the surveys told us that people and their representatives felt their needs were met to a satisfactory standard. Care Homes for Adults (18-65 years) Page 14 of 32 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. The service supports people to follow personal interests and activities and they are able to participate in the local community. This ensures their social needs are met by this service. Evidence: In the annual quality assurance questionnaire completed by the service, they told us they encourage all people to have the opportunity for personal development, by allowing individuals to continue to develop the skills they have. They said they encourage people to access a particular hobby, or undertake domestic skills. They also told us they ensure people have the continuing opportunities to fulfill their spiritual beliefs. Discussion with staff and observations during the visit confirmed that the daily routines Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: of the service are flexible and individuals were able to move freely within the building. Information was available to support the planned activities each person participants in during the week. These included activities provided inside the service and some external activities such as college, art and craft clubs, Gym, snooker, and horse riding. One person we spoke to told us the staff are trying to arrange a college course for a couple of days a week, she told us: sometimes I get bored as I used to go to a day center but I live to far away now, but things are now being sorted for me. The care records looked at indicated that people enjoyed activities in the local and wider community such as, clubs and discos, church, meals out, and walks. During our visit we observed one person having a aromatherapy treatment and they told us, It was very nice and relaxing, I am having a pampering day today. We also observed staff interacting and supporting one person to play a board game. No other activities were observed and people were watching the television for most of the day. People told us they were looking forward to going out in the evening to an organized disco which they attended once a month. The feedback in the surveys we received told us that the provision of community based activities could be improved. Their was evidence in peoples files of the ongoing support provided to enable individuals to keep in touch with their family and friends. People spoken to said this was very important to them. Observations supported that peoples dignity and rights are respected in their daily lives. People told us the food provided was ok, and that they had choices. The menu was displayed in a written format which most of the people cannot access. The staff verbally tell each person the choices available. For those people who cannot verbalise their choice, the staff told us they choose on their behalf, based on the persons likes. There was brief information available in people files concerning their food preferences, which could be extended especially for those people who cannot verbalize their choices. We had a look at the menu and noted that some foods were repeated during the same week, which means the menu is not balanced. A brief visit was made to the kitchen and good standards in the record keeping were maintained. Care Homes for Adults (18-65 years) Page 16 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples current health care needs are not reflected in a person support plan, this has the potential to compromise the way their health needs are met. Evidence: In the annual quality assurance questionnaire completed by the service, they told us they pride themselves in delivering quality personal care and support to people, and that each person has a detailed care plan in place so staff can meet their needs. However as mentioned previously we found that one person did not have a care plan completed by this service and the care plan in one file was out of date. This means staff do not have access to updated written information to enable them to support peoples needs. In the assessment the service told us they ensure people have access to all relevant health care professionals, and they monitor peoples identified health needs and complete the required records. Their was information is one persons file to support the contact with health care professionals, and records were in place to monitor aspects of the persons health. However their was no updated care plan records available in the Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: second file detailing how their health needs should be met, and to support the contact they have had with health care professionals. Staff spoken to told us, this person has accessed health care services, and some notes were found in the well being notes to support this, but they did not link in with a care plan. Health care risk assessments were in place, but these have not been reviewed in accordance with peoples change in needs. For example a moving and handling assessment states a person can mobilize but observations supported that this person was unable to mobilize at this present time. The staff team were able to demonstrate how they support this person with their mobility but this practice was not underpinned by an updated risk assessment. We observed that some people have been diagnosed with onset of dementia and have physical disabilities. Staff have received training in safe manual handling and hoists are now in regular use. The records seen demonstrated that some staff had watched a DVD about Dementia. Staff told us they would like to access formal training in this area in order to gain further skills and knowledge. People spoken to told us they were supported in a way they liked, and observations indicated that support was provided in a respectful and dignified way. Feedback provided in the surveys also supported this. The staff team consists of both males and females, this enables people to choose the gender of the staff they wish to provide their support. It was stated in the information we received that all people have their medication administered by the staff team. Examination of the arrangements for the receipt, storage and administration of medicines indicated that these are generally satisfactory and that all entries in the written records had been made properly. Medication is stored securely, and records supported that staff have received medication training. An assessment of staff members competency based on their practice has not yet been completed to ensure their practices are safe. Care Homes for Adults (18-65 years) Page 18 of 32 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 are protected by having their rights to complain upheld and through staff understanding their responsibilities to report concerns. Evidence: In the annual quality assurance questionnaire completed by the service, they told us they have a complaints procedure in place, and that a detailed record of any concern or complaint is kept accompanied by the outcomes following the investigation. We saw a copy of the complaints procedure displayed in the foyer area. This is available in written format, which people cannot access. However people told us if they were not happy they would tell someone. In the information we received from the service we were told that no complaints have been received since our last visit. We could not view the complaints record as this could not be located by the new acting manager. The CSCI have referred one complaint to the service, and these records were in place. This was about people not accessing activities due to funds not being made available. Evidence was provided of financial transactions and of outings people had undertaken. However the service recognized that more external activities could be facilitated and additional audit system was implemented to assist with the management of peoples finances. Care Homes for Adults (18-65 years) Page 19 of 32 Evidence: The service follows the local safeguarding vulnerable adults procedures. An accessible procedure is not currently available for people with communication needs, but we were told this is an area the service wants to improve upon. The staff team and acting manager were clear about their responsibilities should they witness or be made aware of any incident where the safety of people is compromised. There have been no instances in the past year of any safeguarding Vulnerable Adults incidents. The training records indicate that all new staff have received training in these procedures when they start work (induction). Further training is currently being arranged for all of the staff team. People have requested for their finances to be managed by the staff team. We examined the systems in place and these were found to be satisfactory. A new audit system was due to be implemented. Care Homes for Adults (18-65 years) Page 20 of 32 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 accommodation provided had sufficient facilities and space to enable individuals to lead the life they chose and meet their needs. Evidence: In the annual quality assurance questionnaire completed by the service, they told us the building meets the regulations. A description of the facilities is included in their statement of purpose. They told us that all of the required policies and procedures and servicing records were in place to ensure both the equipment and the building is safe for people. During our visit we saw that some of the communal areas of the building were being re-painted. We looked at the annual maintenance and ongoing refurbishment plan which demonstrated the continued investment to the building. Work was planned to make the en-suites in peoples bedrooms full wet rooms, in order to improve access for people. During our brief tour of the building we saw many aids and adaptations to assist people with their mobility. Peoples bedrooms, were personalized to the individuals preferences. People told us they are able to choose what color they would like and how Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: their bedrooms looked. They told they can have a key if they wanted to lock their bedrooms. People were unsure if they had lockable storage in their rooms, but said they may not use this facility anyway. All of the people spoken with confirmed they were happy with the decor of their home and standards of hygiene in place. Care Homes for Adults (18-65 years) Page 22 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The shortfalls in the way staff are recruited, inducted and the lack of formal supervision impacts on the way people are safeguarded and their welfare promoted. Evidence: In the annual quality assurance questionnaire completed by the service, they told us all staff have detailed job descriptions, and have competent and sufficient training to fulfill their roles. They also said all required recruitment checks as defined by the standards are completed. Information provided in this assessment also us that there are currently 5 staff members who have achieved a National Vocational Qualification to level 2. The service now has a full occupancy, and at the time of our visit there was a team leader and two support staff supporting eleven people. The staff rotas identified that five staff was working the afternoon shift in order to take people out to a function. Additional staff have been recruited by the new acting manager as it was felt sufficient staffing was not available previously to ensure activities were provided. We were told a full complement of staff was now in place, and staff levels are based on peoples needs and to facilitate planned activities. We was also told that any gaps in the rota were nearly always met by colleagues covering for each other and by the use of the homes Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: relief staff. Observations supported that the staff members had a good knowledge of peoples support needs and provided assistance in accordance with peoples preferences. A key worker system is in place, which means individuals have a named staff member they can go and talk to. Discussions with staff members, and the feedback in the surveys, indicated that the team are going through a period of change due to new staff working alongside them, and the change in the managers position. Some staff told us they were anxious about potential changes to the way they worked, but told us they would work in the best interests of the people who lived in this service. We examined the recruitment files for 2 of the most recently appointed staff members. Each file contained majority of the recruitment information that is required by the current regulations in order to protect people that use this service. The shortfalls identified include; a full employment history was not requested on the application form, and therefore this was not provided. A contract and job description was not available in either file to support the positions they held in this service. There was no evidence that both staff had received a service specific induction, or a formal induction. These are required to ensure staff become familiar with the building and administration and receive training on how to fulfill their roles working with this specific client group. Both shortfalls have been identified by the acting manager to be addressed as soon as possible. There was evidence in these files to support training that had been undertaken in their previous employment or through attending college. However for one person this training did not cover all of the mandatory training areas so further training was being planned. We looked at the file for a long serving member of staff, and a training record was in place, which indicated that all mandatory training had been undertaken. However this training consisted of watching a DVD within the service. In response to the staff feedback about their skills and training requirements, the new acting manager is now planning external training to ensure staff have accredited training. This will enhance their skills, knowledge and the support they provide to people. Staff spoken to and feedback in the surveys told us they are motivated and committed to their role. They said they enjoy supporting people and working hands on. They said they have not received formal supervision for a long time although verbal support has been provided. No records of supervision sessions could be located. A staff meeting was planned for the day of our visit and records supported that previous meetings had been held, which aids the sharing of information within the service. Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: People spoke positively about the staff team and the following comments were made: The staff here are nice and supportive the staff are nice and friendly and help me when I need them to. Care Homes for Adults (18-65 years) Page 25 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is not currently managed in peoples best interests due to the shortfalls in the record keeping, and the lack of systems for gaining their feedback. Evidence: The annual quality assurance questionnaire we received was completed by the previous manager who left the service in March 2009. The evidence provided in this section of the assessment was brief and some sections were incomplete. The information provided was specific to the qualifications and management style of the previous manager. Therefore there was no applicable evidence to demonstrate how the service meets the standards in this outcome area. The new acting manager had started working at this service a week before our visit. She has previous management experience and she is qualified for her role. She has not yet applied to register with us but intends to start this process in the near future. She is currently undertaking an induction to the service, which is being provided by the providers. Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: In order to obtain feedback and to assess the service being provided, the manager has requested for each staff member to complete a questionnaire covering a variety of topics about the service, training, and the needs of the people that live here. The results have identified several gaps in staff members knowledge and skills. An action plan is currently being devised to address these shortfalls, and to improve standards for people. There is one internal quality assurance system in place to obtain feedback from people, about the service. A system is not in place for their families or other people involved with the service. People have had two meetings with a advocacy service and the areas discussed are recorded and given to the manager. The records of the first meeting were available and this identified peoples satisfaction with all areas of the service. People did comment they would like more external activities to be provided and we were told arrangements are in place to promote this. The feedback provided in the surveys from relatives and Care managers told us they were satisfied with the service provided and the way the service was managed. Comments from relatives were commentary to the staff team and the way they supported people. There was no evidence other than the advocacy meeting to demonstrate how the service involves people in decision making, about their daily lives or the way the service is managed. We were told these areas will form part of the action plan currently being developed to address the shortfalls and improve standards. We were told that monthly monitoring visits have been undertaken by the providers in order to monitor the standards in place, but copies of the completed reports could not be found in order to assess the content of these. Therefore a new process would commence and a visit would be completed again for March. Information within the pre inspection self-assessment document stated that all of the required health and safety practices at the service were satisfactory. As stated earlier in this report arrangements have been made for staff to access formal training in all of the mandatory areas. Fire training had been arranged for the day after our visit which all staff have been instructed to attend. Care Homes for Adults (18-65 years) Page 27 of 32 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 32 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 6 15 Peoples care plan must be reviewed on a regular basis. This is to ensure staff have access to current information about how to meet peoples need. 30/06/2009 2 6 15 A care plan must be completed for each person following their admission to this service. This is to ensure staff have information to meet peoples needs. 30/06/2009 3 19 17 Each person must have a plan and an assessment in relation to identified health care needs and how often these are to be monitored. This is to enable the staff to meet peoples health care needs. 30/06/2009 4 34 17 A full employment history must be obtained when new staff are recruited. 30/06/2009 Care Homes for Adults (18-65 years) Page 29 of 32 This is to ensure people are safeguarded from any risks. 5 39 24 A quality assurance system must be implemented. This will ensure feedback is obtained from people and their representatives about the quality of the service provided. 30/06/2009 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 statement and purpose should be reviewed so that current changes are reflected. An accessible copy should be made available. The care plan should be completed with the person and include how people are empowered to make decisions and how they are involved in decision making in the service. Peoples preferred routines and planned activities should be recorded in their files. The menu should be accessible to people to enable them to make choices. The menu should be reviewed to ensure it is varied and provides a balanced and nutritional diet that meets peoples preferences. Staff should have an assessment of their practice when administering medication to ensure they are safe in undertaking these tasks. A record should be in place in order to record any complaints received. Accessible information in relation to safeguarding should be provided for people who live in this service. The staff team should access courses in relation to the client group they work with. The application form should request a full employment history. So applicants can provide this information. Page 30 of 32 2 7 3 4 5 16 17 17 6 20 7 8 9 10 22 23 32 34 Care Homes for Adults (18-65 years) 11 34 The staff should have job descriptions of the role they are employed in, and contracts of employment in their recruitement file. Staff should be supervised at least 6 times a year. The acting manager should process her application to CQC. Staff should access formal training in the required mandatory areas to ensure they have the required skills for their role. 12 13 14 36 37 42 Care Homes for Adults (18-65 years) Page 31 of 32 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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