Inspection on 12/02/09 for The Pembury

This inspection was carried out on 12th February 2009.

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

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

Other inspections for this house

The Pembury 19/02/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: The Pembury The Pembury 9 Pembury Road Gloucester Glos GL4 6UE 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: Odette Coveney Date: 1 2 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. They reflect the things that people have said are important to them: 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. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 30 Care Homes for Adults (18-65 years) Audience Further copies from Copyright 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 30 Information about the care home Name of care home: Address: The Pembury The Pembury 9 Pembury Road Gloucester Glos GL4 6UE 01452521856 01452303418 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mrs Sharon Foran,Miss Deborah Bayliss care home 8 Number of places (if applicable): Under 65 Over 65 8 0 learning disability Additional conditions: Date of last inspection A bit about the care home The Pembury is a converted guesthouse in the St Barnabas area of Gloucester. It is a detached house that provides accommodation for up to eight adults of either sex with Learning Disabilities from eighteen to sixty five. The house has accommodation on the ground and first floor. All bedrooms have en-suite accommodation and four are located on the ground floor. On each floor there is an assisted bathroom and Care Homes for Adults (18-65 years) Page 4 of 30 toilet facility. On the ground floor there is also a large communal lounge, separate dining room with quiet computer area, kitchen, sensory room and laundry. The Managers office is on the first floor. All the accommodation meets the current environmental standards. To the front, back and side of the property is garden area screened by a fence with a patio are at the rear, all of which is well maintained. There is a car park for several cars to the rear of the property with on road parking at the front of the home. The home is staffed twenty four hours a day and Manager is in day to day charge of the home. Fees charged at the home range from four hundred and fifty pounds per week to nine hundred and fifty pounds per week and is dependent upon individuals assessed needs and support requirements. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 30 How we did our inspection: This is what the inspector did when they were at the care home This unannounced key standard site visit, it was carried out by one inspector, in one day and took 7 hours to complete. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individuals living in the home. During this visit we spoke to people living and working at the home. The Registered Providers were also present during our visit and assisted fully with the inspection. Records in respect of the support provided to people living at the home were reviewed as were staff files to review recruitment practices, training and supervision of staff. Fire and safety records were also reviewed by us. , What the care home does well There was evidence that staff focus on the individual needs of people who use the service and create a homely place for people to live. There is a commitment to provide a wide range of leisure and social activities. Individuals living in the home benefit from Care Homes for Adults (18-65 years) Page 7 of 30 a consistent staff team. Staff spoken with enjoy their work and talk about good staff teamwork and of an open supportive relationship with the manager and owners of the home, which includes good supervision. People we spoke with told us they like living at The Pembury, that they get on well with the staff and that they have made friends both inside and out of the home. People told us how the home support them to maintain relationships with their family and to participate in social activities of their choice. What has got better from the last inspection During our last visit to the service we reported that The Registered Person must ensure that medication administration records must be amended to contain clear information in respect of allergies and this must be recorded on the medication administration sheet. We saw that this had been completed. We also reported that individual photos must be on the medication file, photographs for all were in place. We also said that the homely remedies agreement from the GP must state which over the counter medicines could be given with dosage etc. We saw that this information had been obtained and had been recorded as required. At out last visit we made a requirement Care Homes for Adults (18-65 years) Page 8 of 30 that The Registered Person must ensure that all new staff have a current Criminal Records Bureau check in place before they start work, protecting people from possible harm. All staff have a Criminal Records Bureau Check in place before commencing work at the home. The Registered person have produced an annual quality assurance report. This evidences the review of the quality systems in the home. This includes stakeholders views and outlines the future developments in the home. The Registered Person must ensure that a risk assessment is documented for staff starting work on a POVA first check, describing how people are protected from possible harm. The manager confirmed that there are no staff working at the home who do not have CRB clearance in place before commencing work. What the care home could do better House hold risk assessments must be reviewed in order to ensure that the information contained within them is still valid and contains correct information and guidance to inform and direct staff practice. A review of the risk assessments in place Care Homes for Adults (18-65 years) Page 9 of 30 for those living at the home should be undertaken in order to ensure that the information within the assessments is still current and appropriate. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Odette Coveney 33 Greycoat Street London SW1P 2QF 02079792000 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 10 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Information is in place about the facilities and services provided at The Pembury. Clear contractual arrangements are in place outlining individuals rights and responsibilities Evidence: The information within the Statement of Purpose for the home was comprehensive and contained clear information for individuals and their relatives about the services and facilities provided at the home. The aims and objectives of the service are recorded as follows: We believe that by creating a supportive environment all adults with learning difficulties have the ability to participate in the community. We aim to maximise service users potential for independence both inside and outside of the home. The document contained information about the staff arrangements at the home, information about the admissions process into the home and how to raise issues of concern and how these would be responded to. This document is kept under review by the manager of the home and is updated when required. The home was registered with The Commission for Social Care Inspection (CSCI) in Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: August 2006 to provide personal care and residential services for up to eight adults with a learning disability. There are no vacancies at the home at this current time. There is an admission procedure, which is included in the statement of purpose and full assessments of needs were undertaken. The care files reviewed during this site visit showed evidence of detailed pre-admission assessments to enable staff to develop personalised care plans of individuals and these record how the needs were to be met. Care plans, which have been developed by the home, were found to be extremely detailed and well written. Each individual had in place a contract detailing the terms and conditions of stay at the home and provided clear guidance on the rights and responsibilities of both the service user and the registered provider. Information within this document also includes clear information about fees and services to be provided During our visit staff were observed interacting with individuals, in familiar, friendly manner. Care Homes for Adults (18-65 years) Page 13 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Care plans are well written and enable staff to provide a consistent and individualised care. Those who live at the home are involved with the personal care planning process and the homes philosophy promotes individuals personal development, self direction and empowerment. Individuals are supported to take risks without hindrance or impacting on their safety. Evidence: The home operates a key working system whereby each person living at the home has a named support worker who plays a more central role in co-ordinating the care and support they receive. This provides meaningful staff support to individuals, which is particularly important to those who have complex needs. We reviewed in detail the care plans and associated health, social and lifestyle records for three of the people who live at the home. The care plans seen at this visit were detailed and explicit and contained all of the required individualised, person centered information. The daily reports contained entries of what, when and how care was Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: provided. Information recorded on care documentation corresponded with information given to us by the manager and staff about the individualised levels of support that people living at the home received. We saw that individuals had recorded their preferred routines, these remain flexible and services are tailored to the needs of the individuals on the day. Recorded routines were very detailed and gave clear direction for staff in respect of individuals preferences and choices to minimise their anxiety and to respect individuals choices. People living at the home are supported to take risks as part of a lifestyle to promote independence, information seen within assessments provided clear information on which decisions have been based. Action is taken to minimise risks and hazards and people are provided with appropriate support to minimise identified risks and hazards, assessments seen included aspects of daily living, support with personal care and social and community activities. Records showed that assessments had not been reviewed, this should be undertaken in order to ensure that the information within the assessments is still current and appropriate. Care Homes for Adults (18-65 years) Page 15 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Individuals have opportunities to participate in activities both in the home and the local community. Good contact is maintained with friends and relatives. Individuals have a health and varied diet. Evidence: People living at the home are supported to become part of, and participate in, the local community in accordance with assessed needs and individual plans. Staff enable those living at the home to have full integration into community life through knowledge and support to enable individuals to make use of services, facilities and activities in the local community, such as shops, pubs, and places of local interest. Information seen by the us during our visit, and confirmed by staff and what was seen on individuals records showed that those living at the home are offered a variety of social and leisure activities. Individuals are able to participate or not, this is dependent on the individuals Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: choice. Information seen in daily records evidenced that individuals regularly take part in the following activities such as: attendance at local community groups and clubs, cinema, horse riding, swimming and shopping. During our visit we viewed individuals daily diaries, these contained full information about the range of activities that people had been involved with such as special family and social events. These diaries were enhanced by the use of photographs in which people appeared to be enjoying themselves and having a good time. Staff support individuals to maintain family links and friendships inside and outside of the home and this is facilitated by staff escorting individuals on visits to family members. The manager was fully conversant with respecting the rights and choices of individuals and was able to demonstrate that the home would access specialist guidance if required in order to help those living at the home to make appropriate decisions and would be supported. During our visit one of the people who live at the home told us about the meal they had made for tea that evening, chicken curry. They told us they enjoyed cooking and preparing meals and that staff were kind and helped them to maintain and support their independence. We viewed the kitchen and saw that it was clean and tidy. We saw that in February 2007 the home achieved a five star food hygiene award issued by the local council environmental health department. Five stars in the highest award for food hygiene and safety that can be issued. Care Homes for Adults (18-65 years) Page 17 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Individuals are well supported by staff and external agencies with all aspects of their personal, physical and emotional well being. Legal requirements in respect of medication are appropriately managed at the home. Evidence: Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individuals. The staff team have a varied range of knowledge and skills, they were observed by us to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. Individuals had on their care plan files information, which outlined the support they required with their personal care. Staff ensure consistency and continuity of support for those living at the home due to people having a designated key worker and also there is clear information recorded in daily diaries which sets out their preferred routine, likes, dislikes and communication methods. From talking with staff it was evident they enjoyed working at The Pembury, that they Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: felt supported in their roles and had built good relationships with the people they support. Staff were knowledgeable about the needs of the people living in the home. There was evidence of visits from the doctor, occupational therapist, optician, chiropodist and other health professionals on the care files reviewed. Records showed that individuals had attended hospital appointments when needed and were supported with any associated treatments. At our last visit to the service undertaken in 2007 we recorded that attention was required by the home within the following areas in order to ensure that the home were following their own internal policies and procedures in respect of medication. These were that the Registered Person must ensure that medication administration records are amended to contain clear information, this included that allergies must be recorded on the Medication Administration sheet. Individual photos must be on the medication file. And also that the homely remedies agreement from the GP must state which over the counter medicines could be given with dosage etc. During this visit we reviewed medication practices at the home. This included a review of the administration, recording and practices. We saw evidence to demonstrate to us that the requirement had been met. Information recorded within medication administration sheets corresponded with information we had seen in individuals care plans. We saw that photographs were in place for all people who live at the home, clear information had been recorded about the use of homely remedies. Care Homes for Adults (18-65 years) Page 19 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . There are clear guidelines, policies and procedures in place to ensure that individuals are protected from abuse, staff receive training in this area. Evidence: The home has a complaints policy and procedure. A copy of the complaints procedure is available upon request. All complaints would be fully investigated and a record kept. he home has adult protection and whistle blowing policies and staff have undertaken training in this area. A copy of the joint policy and procedure for safeguarding adults was on prominent display in the main office outlining the roles and responsibilities of the local authority, individual services, the primary healthcare trusts and the police ensuring a consistent and thorough approach. The manager has also arranged to undertake training in respect of the Mental Capacity Act in order to ensure that she is aware of current legislation and the legal rights of those who live at the home, this information will be shared with the staff team. Care Homes for Adults (18-65 years) Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The quality of furnishings and fittings in the home is good and overall a warm comfortable environment has been created ensuring individuals needs are met. Evidence: The Pembury is located within a residential area of Gloucester. The home is in keeping with surrounding houses and close to local amenities and shops. The homes premises are suitable for its intended purpose, its accessible, safe and well maintained and meets service users individual and collective needs in a comfortable and homely way. The home was found to be well furnished with soft furnishings such as pictures, plants and photographs making for a homely environment. Communal areas for individuals use were found to be clean, tidy and odour free. Domestic staff are employed at the home and were seen working diligently on the day of our visit. The gardens to both the front and rear of the home are attractive and well maintained. All of the bedrooms in the home are for single occupancy and all have en suite facilities, one of the people living in the home invited us to their room. We saw that the home was well furnished, comfortable and had been personalised in order to Care Homes for Adults (18-65 years) Page 21 of 30 Evidence: reflect the individuals hobbies and interests. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The numbers and skill mix of staff on duty meets individuals needs. Staff are trained and competent to do their job. The home has recruitment policies and procedures that protect those who live at the home. Evidence: Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individuals and have worked together with them and others in order to identify the needs of service users and then support the person in achieving their goals. There was information in individual care plans that provided information to guide staff to the appropriate level of support that individuals require. Regular staff meetings and team days are held at the home and appropriate subjects are covered in respect of the service provided at the home and are in line with the assessed needs of those living at the home. Morale is good within this home and staff spoke positively about their role and the work they do. Staff were able to give a number of examples of areas within their role Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: which gave them job satisfaction such as one to one time with individuals, supporting individuals in they way they prefer and supporting people with their activities and accessing the community. Relationships between staff and those who live at the home were directly and indirectly observed throughout the course of the visit. Staff were seen to respond to people appropriately and work to protect their need for privacy and dignity. Staff demonstrate a friendly, supportive and caring approach when supporting people at the home. During our last visit to the home a requirement was made in respect of staff recruitment this was that the Registered Person must ensure that all new staff have a current Criminal Records Bureau (CRB) check in place before they start work, protecting people from possible harm. During this visit we reviewed the files for members of staff, these included recruitment and selection records. We saw that each staff member had a CRB in place, two written references. At our last visit we also required that the Registered Person must ensure that a risk assessment is documented for staff starting work on a POVA first check, describing how people are protected from possible harm. This was complied with by the providers and is no longer relevant. We saw that the home had requested, and had in place a POVA first a check. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The Home benefits from good leadership and management its practices have offered protection to the health and safety of those who live at the home. The home is run in the best interests of individuals. The home is well managed ensuring that individuals interests and rights are promoted and protected by a committed staff team. Evidence: During the visit the manager Sharon Foran was able to demonstrate a clear understanding of the aims and objectives of the home and of her role and responsibilities for those who live at the home and the staff team. Sharon has over eight years experience of supporting people with learning difficulties, she also has a Btec in business studies and a National Vocational Qualification at level 3 in care. Sharon had submitted an application to us in order that we may interview her and Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: determine her fitness to manage this care service, however, since this key visit was conducted we have been informed that Debbie Baylis, the registered manager of the Padova care home will also manage The Pembury, this has been agreed with us due to the uniqueness of the services and also due to both of the registered providers working closely together with an ability to demonstrate a consistant level of quality service for those living at the Pembury. On 6th July 2008 we completed an annual review of the service. We do an annual service review when there has been no major inspection of the service (we call with a key inspection) within the last twelve months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection. At this review we confirmed that we had not changed our view of the service and that The Pembury continued to provide good outcomes for the people living at the home. Prior to the site visit the Commission requested from the Registered Manager a completed an annual quality assurance assessment. The annual quality assurance assessment (AQAA), this is a new process that is being used for all regulated services from April 2007. The AQAA is in two parts: Part one is a self assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. Within the completed AQAA the service reported that they Provide high quality care for our service users in a homely environment in which they can feel secure. Care is provided by trained staff who promote service users safety and dignity in an antidiscriminatory environment. During our last key visit to the home we required that the Registered Person must produce an annual quality assurance report to evidence the review of the quality systems in the home. We saw that the home had completed a quality audit of their service in January 2009. This incorporated the use of questionnaires. We saw that these had been completed by people who live at the home and their relatives. Overall client satisfaction was rated as excellent, comments from those who live at the home included; its very nice here, there are nice people here who I live with I enjoy all of the activities. Feedback from relatives of individuals who live at the home included; The care and commitment given by the management and staff enables service users to fulfill their individuals potential, My relative has never looked so well looked after The Pembury provides a happy safe environment. A review of the fire logbook found that staff are receiving sufficient fire instruction and drills, maintenance and equipment checks are undertaken on a regular basis. All weekly, daily and monthly checks have been recorded. We saw that that the home had in place a detailed fore risk assessment, it identified who was at risk and the existing safety provisions. During our visit we reviewed the risk assessments in place which had been completed in respect of household activities. We saw assessments in place for areas such as use of the mini bus, the checking of water temperatures, kitchen activities and safe garden use. We saw that these assessments had been completed in September 2007 and had Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: not been reviewed since then. It is required that house hold risk assessments are reviewed in order that the information contained within these assessments is correct and that appropriate measures are in place to ensure the safety of those who live and work at the home. The home have maintained records of fire training, and emergency lighting is checked on a monthly basis, this is recorded. We saw on display that the home had a certificate evidencing that appropriate liability insurance was in place. Care Homes for Adults (18-65 years) Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 30 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description 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 Description 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 9 It is recommeded that risk assessments for service users are reviewed This should be undertaken in order to ensure that the information within the assessments is still current and appropriate. House hold risk assessments must be reviewed. 2 38 Care Homes for Adults (18-65 years) Page 29 of 30 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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