Inspection on 22/01/09 for Westcliffe House

This inspection was carried out on 22nd January 2009.

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

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

Other inspections for this house

Westcliffe House 26/04/10

Westcliffe House 24/01/07

Westcliffe House 11/12/05

Westcliffe House 14/10/04

Westcliffe House 13/05/04

Westcliffe House 24/02/04

Similar services:

Clouds House

Closereach

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: Westcliffe House 12 Madeira Road Weston Super Mare North Somerset BS23 2EX     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Paul Chapman     Date: 2 2 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Westcliffe House 12 Madeira Road Weston Super Mare North Somerset BS23 2EX 01934629897 01934620369 westcliffehouse@btconnect.com 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) : Westcliffe House Limited care home 20 Number of places (if applicable): Under 65 Over 65 0 0 past or present alcohol dependence past or present drug dependence Additional conditions: Date of last inspection Brief description of the care home 20 20 Westcliffe House House is a rehabilitation unit for up to 20 service users who have been through detoxification and are now embarking on an individualised therapeutic program working towards rehabilitation from addiction. The home is situated near the beach and within easy access of local amenities, bus and train services. The home also makes use of the amenities provided by Weston College for education purposes. Care Homes for Adults (18-65 years) Page 4 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: Before completing this site visit we reviewed the previous inspection report, other information gathered since the previous inspection and the AQAA (Annual Quality Assurance Assessment). The AQAA was dated 04/12/08 and provided us with information about what the manager feels the service does well, what has improved since the previous inspection was completed and what improvements are planned for the next 12 months. In addition to this information it also provides us with a dataset, this is information about staffing, procedures, complaints, training and health and safety. Before completing the site visit we sent questionnaires to people using the service, staff and other professionals involved with the service. We received 5 completed Care Homes for Adults (18-65 years) Page 5 of 29 surveys from people using the service, 5 from staff, 3 from GPs and 3 from care managers. Supporting us to complete this site visit was an Expert by Experience. Whilst we spoke to the management team of the centre they met with a group of people to discuss what they thought about the service they were receiving. This inspection site visit was completed over a period of 7 hours in January 2009. We examined recent admissions to the centre, the assessment process, care plans, risk assessments and other associated paperwork, in addition to this we completed a tour of the premises with the management team. What the care home does well: Comments from the completed questionnaires we received included; People using the service told us The manager is very open and listens to what we have to say. She is approachable and objective. I think the standard of living at Westcliffe House is excellent. The staff are friendly and helpful. They listen and I respect and trust them. If I feel emotional I can speak to my peers or the therapist. staff are caring, they have loads of time for me, they are concerned for me. Westcliffe is a good place to be, its very professional. Staff told us There is an open door policy and staff are always on hand to discuss issues that may come up. The service is adaptable and flexible to meet peoples needs. We respect peoples rights, dignity and offer a person centred approach in the development of empowerment to the individual. There is an environment of openness and support for people that allows them to find inner-self. Westcliffe has a family atmosphere. Other professionals told us This centre has produced remarkable results with a broad range of people needing therapeutic intervention. Staff are always approachable, they appear relaxed, they do not judge, Westcliffe feels homely. Feedback from people using the service has always been positive. They provide an excellent care package for people who have substance misuse problems. The Expert by experience that supported us on the day of the site visit came to this conclusion: - Care Homes for Adults (18-65 years) Page 7 of 29 My overall impression of Westcliffe house is a good one. All of the people are involved in their treatment and the general running of the house, there is a good atmosphere between people and staff. Literature is readily available to people living in the centre and visitors. I found the environment of the home very relaxed yet very well structured. I found the staff and people living in the home pleasant and accommodating. People are thoroughly assessed before they are offered treatment and this minimises the risk of people entering the centre who are not committed to treatment. Each person has a range of goals in their care plans that they are involved in developing and reviewing. The service provided in the centre is led by the needs of the people residing there and the aim is to provide people with the self-confidence and skills to remain substance free after leaving the centre. People admitted to the centre are encouraged to address any of their medical/health issues as part of their treatment. The centre provides people with a comfortable, clean and homely environment that meets their needs whilst they are resident there. People staying at the centre are supported by a committed and appropriately qualified staff team to help ensure that their needs are met and their recovery continues. The manager provides the staff team with good leadership and is committed to meeting the needs of the client group. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are thoroughly assessed before they are offered treatment and this minimises the risk of people entering the centre who are not committed to treatment. Evidence: Initial referrals are taken over the phone with the person. This method is used as it enables that manager and her staff team to judge the persons commitment to wanting to start treatment. After initial referral there is usually a period of 1 to 2 weeks before the person is invited to the centre for an assessment. This period gives staff the opportunity to complete further research into the person. When the person attends the centre for assessment it will be completed face to face with either the manager or 1 of the 3 senior staff. This assessment may take up to 2 hours and as part of the process the person will be introduced to people receiving treatment and be able to look around the centre. We witnessed an assessment being completed at the time of our site visit. When the assessment is completed the person will be given an information pack that provides them with comprehensive information about the centre and what they can expect if they are admitted. A copy of the house rules is included in Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: the pack to ensure that people are clear about the rules before they enter the centre. As part of the pack there is a letter that the person must sign and post back to the centre confirming they would like to receive treatment. On admission to the centre staff will go through day to day policies with a person, they are then asked to sign in agreement that they have read and understood the policies. They are given an information pack to keep throughout their stay in the centre. As part of the admission process 2 people already resident in the centre will become be-frienders and support a new admission through the first 2 weeks of residence. Comments made to the Expert by Experience about the assessment process confirmed that the above process is followed. All of the people spoken with reported they were very happy with the assessment process and felt it was clear and to the point. People highlighted that they all felt listened to, and were not judged by their addiction and there was a good level of communication and understanding of the issues they had. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person has a range of goals in their care plans that they are involved in developing and reviewing. The staff support people to achieve their goals. Whilst at the centre a wide range of measures are taken to minimise potential risks to people. Evidence: We examined care records for 4 people. 1 person was no longer residing at the centre and this enabled us to judge how aftercare was arranged. On admission to the centre people are assigned a key worker and it is aimed that this person will support them throughout their stay in the centre. Care plans with goals will be agreed with each person, these cover 5 recognised areas: - to remain substance free, childhood and family/underlying issues, education assessment/employment, social networks with substance abuse, and achieving optimum health and maintaining it. All of these areas are reviewed monthly with the persons key worker in a 1 to 1 session. In these sessions people will be asked for their opinion on their progress. All of the records we examined contained detailed notes completed by a senior specialist therapist. We Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: spoke to the 3 specialist therapists individually who were all very committed to the service they provide and highly experienced in the field of substance misuse. Records provided clear evidence that the goals for the 5 areas identified above were being met. We had a discussion with the manager about the personal goals that people may enter the centre with. An example of this may be re-establishing links with children/family. We were able to see an example of a person being supported to do this. When people are admitted to the centre people will attend sessions throughout the day and their free time starts after 4pm. When people do go out they are not allowed into establishments that serve alcohol, or where gambling is taking place. People can attend church (or gatherings of other faiths) if they wish. There is no expectation that people need to attend a minimum number of AA/NA groups per week. Menus were examined and showed that there is a choice of main meals each day, but people are expected to be seated 5 minutes before food is served and must stay seated at the table until all people have finished. The centre takes a wide range of measures to minimise potential risks to people whilst they are staying at the centre. The Expert by Experience stated: - All of the people I spoke with had a good understanding of a care plan and its purpose. All of the people identified the level of involvement they have had with their care plans, from the stage of initiation, through to reviews and updates. People also reported that they have access to a copy of their care plan and they are involved with any changes to that care plan. All people feel this is a useful tool as it helps them to identify goals and gain a sense of achievement. One person said I like the fact that we have the care plan in place, it makes me feel like an individual and I can go at my own pace. Comments from completed questionnaires included Westcliffe is a good place to be, very professional, staff are friendly, helpful. They listen to me and I respect and trust them. (From people resident in the centre). Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provided in the centre is led by the needs of the people residing there and the aim is to provide people with the self-confidence and skills to remain substance free after leaving the centre. Evidence: Whilst in the treatment centre staff work with people in building and maintaining a positive lifestyle. Models of therapeutic intervention are varied and include: - Drama therapy, art therapy, cognitive analytical, music therapy. In addition to this there are a number specialist groups run each week: - positive parenting, stress management, personal relationships, communication skills and life skills. In addition other activities may be organised within the groups social time, these may include team building exercises, sport, or other leisure activities. Where it is identified that people have literacy difficulties specialist staff are used to undertake 1 to 1 work with them to Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: improve skills. When people enter their last 6 weeks in the centre they are encouraged to start considering their work place skills, whether this means seeking employment or finding a college course to enable them to get back into employment. In addition to the above activities people are also expected to complete certain therapeutic duties around the centre. An important part of treatment is after care. The Expert by Experience spoke to people about this; There were only a couple of people that were at the stage of planning their aftercare. People not at that stage did show an awareness and understanding of aftercare. One person I spoke with is accessing the aftercare service that Westcliffe House provides, their comments on aftercare were my aftercare is centred around one to one sessions, so that gives me the opportunity to identify any other aspects of my life I need to address. I attend the Carlton Centre where I attend cookery sessions, budgeting and general life skills and education and I really enjoy going because I am learning things I should already know but the most important elements of living a life without drugs are cooking, relationships and life skills. Speaking with other people they are aware that aftercare is going to be addressed in their next care plan review. People staying at the centre are allowed visitors with prior permission from staff. As mentioned earlier in this report people have a choice of the food they wish to eat. The manager stated that food is an important part of life in treatment. The menu works on a 3-week rolling rota. For breakfast people have a range of cereals, on a Wednesday people also have the opportunity for poached and scrambled eggs, and on Mondays and weekends a full English breakfast is available. The centre caters for specialist diets where it is required. Further evidence from the Expert by Experience: - All people are encouraged to engage in activities. Activities are available throughout the week and the weekends are also a dedicated time for activities. One person commented on the activities, we are all encouraged to take part in activities and most evenings we play board games or watch T.V or videos, we are also allowed to go for walks and at the weekends we play games like bingo etc. People have a good selection of board games and collection of videos and they are also permitted to have magazines and books as long as they meet the guidelines. All people are allowed to smoke in the lounge after 7.30pm and they have access to teas and coffees throughout the day. People are also encouraged to look out for each other in the evenings and at weekends and be aware of anyone isolating themselves. People I spoke to requested that I feedback on the structure at Westcliffe House and report their positive experiences. The most important thing they feel is the Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: involvement they have in the running of the house and the fact that they are consulted with, and involved in meetings, they also like the fact that they know what they are doing each day. People showed a good understanding of the rules and boundaries at Westcliffe. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People admitted to the centre are encouraged to address any of their medical/health issues as part of their treatment. Medication administration practises minimise potential risks to people in the centre. Evidence: After people are admitted to the centre staff ensure that they registered with a local GP where they are able to have a medical health assessment. In addition to this people are encouraged to join a dentist practise and attend an opticians if required. The centre puts an emphasis on ensuring people are healthy. We examined records of health appointments which were detailed and provided a clear picture of peoples needs and the actions taken to meet those needs. staff to do not support people with their personal care. Medication was examined with the member of staff responsible for taking the lead and overseeing its administration. When people enter the centre they usually hold and manage any vitamin tablets they bring with them but other medication is managed by Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: staff. Any medication collected from pharmacists by people staying in the centre will be sealed in a bag, any evidence that this bag has been opened would be questioned by staff. Medication entering the centre is checked by staff to ensure that it is correct. All staff receive training before they are able to administer medication. Records of medication administration were seen to be thorough and the member of staff responsible for overseeing medication will speak to staff if an error is identified. We identified a couple of shortfalls that we discussed with the manager. Firstly, the keys to the medication cabinet were not stored securely raising the potential risk of non-authorised people accessing the cupboard. In addition to this we found a substantial amount of medication that needed to be returned to the pharmacist. We received an email from the manager after the site visit explaining that as a result of our findings the keys are not locked away and that a member of staff has been given the responsibility for return medication to the pharmacy monthly. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People staying in the centre are able to make a complaint if they are unhappy with the service they are receiving. Staff training in safeguarding adults is ongoing and minimises potential risks to people. The finances of people staying at the centre are thoroughly recorded and this minimises the risk of discrepancies. Evidence: The centre has a complaints procedure and each person entering the centre receives a copy of the document as part of their client assessment pack. Since the previous inspection there has been 1 complaint made to the manager. The CSCI has not received any complaints about the centre. We received 5 completed CSCI questionnaires from people staying in the centre. All responded that they could make a complaint if they were unhappy and felt they would be listened to. One person commented Any issues or grievances are normally quickly resolved. Two of the senior staff we spoke with during the site visit have completed safeguarding training externally and take responsibility for managing any situations potential abuse within the service. All other staff complete internal training. One of the senior therapists is responsible for managing peoples monies while they are resident at the centre. Each person is paid an allowance of 21.15GBP per week and they sign an expenditure sheet to confirm they have received it. Care Homes for Adults (18-65 years) Page 19 of 29 Care Homes for Adults (18-65 years) Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The centre provides people with a comfortable, clean and homely environment that meets their needs whilst they are resident there. Evidence: We completed a tour of the premises with the manager and the expert by experience. We saw all of the communal areas and a number of people staying at the centre showed us their bedrooms. Communal areas provide people with sufficient space to move around freely. During the day rooms are used for group sessions. There are two designated smoking areas, one being the rear garden. The majority of people people have their own bedrooms. The rooms seen by us had been personalised with peoples possessions and speaking with them they were happy with their rooms. The home is decorated to a good standard throughout and there is an ongoing maintenance programme to ensure this continues. Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: At the time of this site visit the centre was clean and tidy. A comment from a completed questionnaire was I think the standard of living here is excellent. (From a person resident in the centre). Care Homes for Adults (18-65 years) Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures are thorough and this minimises potential risks to people staying at the centre. People staying at the centre are supported by a committed and appropriately qualified staff team to help ensure that their needs are met and their recovery continues. Evidence: The previous inspection report made one recommendation, this was for the manager to ensure that all of the staff files contained the information required by these regulations. We examined the staff files for four staff and the sample we examined contained all of the information required by these regulations. Staff meetings are held every Monday morning and minutes were available that detailed what was discussed and actions. When staff are employed at the home they are given a staff handbook explaining all of the relevant information about their employment and role. Each new member of staff completes an induction period of a minimum of twelve weeks. The manager has produced a training development programme for 2009 and this Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: showed that staff will be completing training in: - Health and safety, fire safety, medication, food safety, mental health, safeguarding vulnerable adults, equality and diversity and NVQs (National Vocational Qualifications) in social care. The AQAA highlights that all of the therapists employed in the centre are qualified to post graduate level and two support workers are completing degrees in counselling. The manager explained that they access specialist skills and knowledge from other professionals as required. Examples of this may be employing some one to come into the centre and do a team building session or a talk. As part of this site visit we spoke to 3 of the senior therapists about working at the centre. All of these staff have been employed at the centre for between 11 and 17 years and feel that they are really supported by the manager. All agreed that training is ongoing and that it is a really good place to work. All staff agreed that they receive supervision regularly from an outside agency. We received 5 completed questionnaires from staff before we completed the site visit. Comments from staff supported what we were told at the site visit confirming that they had good access to training, communication was good amongst the team and they felt supported. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager provides the staff team with good leadership and is committed to meeting the needs of the client group. The service is lead by the needs of the people using the centre but evidence of quality assurance is in need of further development to provide a complete picture of the service being provided. Steps taken by staff through regular checks and training minimises the potential risks to people health and safety. Evidence: The manager of the centre is also the co-owner and is an experienced counsellor. Comments from people during the site visit and from questionnaires we received included The manager is very open and listens to what we have to say. She is approachable and objective. Staff commented that they felt the manager was really committed to providing a good service. Speaking with the manager we agree with these comments. The service is well-managed and is clearly run to meet the needs of the client group. We had a conversation with the manager about how they address quality assurance. Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: Annually they complete an analysis of of the services success and failure rate. Figures for August 2007 to July 2008 showed that 41 of people completed at least 20 weeks of treatment. When people leave the centre they are asked to complete a questionnaire about the service they received. The manager keeps the completed questionnaires but does not evidence the action they may take as a result of the comments. We recommend that they develop a system to show that they have reviewed the findings and the actions taken as a result. This will then form part of the services quality assurance procedure. One person commented in their questionnaire, Ive always found staff really helpful and they act upon what I say. Speaking to the manager they explained that each Sunday they chair a meeting with all of the people staying in the centre to discuss the previous week, the plan for the up coming week. This forum allows people to discuss any issues that may concern them. The agenda for the Sunday meeting includes: - Individual Client Therapeutic Reviews of the preceding week, the therapeutic programme from the clients and staff perspective, referrer visits and reviews, household, house points and any other business. This is then repeated in the staff meetings that are held each Monday morning. As well as the Sunday meeting with all of the people staying in the centre there are meetings for groups named Omega, Alpha and prep. These are groups for people at different stages of treatment. Minutes are taken at these meetings and is information is then fed into staff meetings. The AQAA stated that all of the centres policies were reviewed during 2008. We looked at the steps to minimise potential risks to health and safety around the centre. Fire safety precautions are monitored regularly by staff and qualified engineers complete regular services of the equipment. Staff complete training in food safety and health and safety. Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 39 The manager should review the questionnaires completed by people after they leave the service and take corrective action as required. Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (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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