Care Home: 150 Community Drive

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What the care home does well The service has person centred plans in place for everyone.We saw that the there is a good choice of food at mealtimes,The management of peoples’ finance is robust.We saw that people know how to complain.The staff team receive the training and updates they need. What has improved since the last inspection? People using the service have more activities both in and outof the home.Information is available in a format that people using the service can easily understand.People using the service are supported to be independent.The staff team ensure that people using the service receive health checks when they need them.New flooring and furniture has been provided. What the care home could do better: We recommended that medication is recorded better.Mental Capacity Assessments should be requested where concerns are identified.People need to have up to date information available to them about the costs and fees of the service.The service should seek the views of others when assessing the quality of the service. Key inspection report Care homes for adults (18-65 years) Name: Address: 150 Community Drive 150 Community Drive Smallthorne Stoke-on-Trent Staffordshire ST6 1QF The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Wendy Jones Date: 0 6 0 4 2 0 1 0 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:  Be safe  Have the right outcomes, including clinical outcomes  Be a good experience for the people that use it  Help prevent illness, and promote healthy, independent living  Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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 Care Homes for Adults (18-65 years) Page 2 of 34 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 mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 34 Information about the care home Name of care home: Address: 150 Community Drive 150 Community Drive Smallthorne Stoke-on-Trent Staffordshire ST6 1QF 01782839349 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): communitydr@choiceshousing.co.uk Choices Housing Association Limited Name of registered manager (if applicable) Mrs Dawn Patricia Hughes Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 8 0 care home 8 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 8 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) 8 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 34 A bit about the care home 150 Community Drive is a large detached house registered to provide accommodation for eight younger and older adults. Care Homes for Adults (18-65 years) Page 5 of 34 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 health care support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 34 How we did our inspection: This is what the inspector did when they were at the care home This was an unannounced key inspection visit of 150 Community Drive undertaken by one inspector on the 06 May 2010. The visit took approximately 6 hours. We looked at care plans and other records. We spoke to people living at the home and staff. Care Homes for Adults (18-65 years) Page 7 of 34 What the care home does well The service has person centred plans in place for everyone. We saw that the there is a good choice of food at mealtimes, The management of peoples’ finance is robust. Care Homes for Adults (18-65 years) Page 8 of 34 We saw that people know how to complain. The staff team receive the training and updates they need. What has got better from the last inspection People using the service have more activities both in and out Care Homes for Adults (18-65 years) Page 9 of 34 of the home. Information is available in a format that people using the service can easily understand. People using the service are supported to be independent. The staff team ensure that people using the service receive health checks when they need them. Care Homes for Adults (18-65 years) Page 10 of 34 New flooring and furniture has been provided. What the care home could do better We recommended that medication is recorded better. Care Homes for Adults (18-65 years) Page 11 of 34 Mental Capacity Assessments should be requested where concerns are identified. People need to have up to date information available to them about the costs and fees of the service. The service should seek the views of others when assessing the quality of the service. Care Homes for Adults (18-65 years) Page 12 of 34 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 Wendy Jones 77 Paradise Circus Queensway Birmingham W Midlands B1 2DT 01216005300 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 13 of 34 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and health care 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 14 of 34 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. Prospective users of the service have access to information about it in a format that is user friendly so that they can easily understand the type of service it is an if it is suitable for them. Evidence: The service told us in the AQAA that, We have a clear statement of purpose, and service user guide which has been reviewed recently. Our admissions policy is consistent with the statement of purpose, which is reviewed at least annually. Admission for a service user would only be agreed following an assessment of our ability to meet individual needs and the suitability of the service user within the current home. All service users have an individual license agreement. All service users have a rent card which they have signed at the office. We found that information about the service is available to people who live there and for any prospective user of the service, in the Statement of Purpose. This is a book that tells people who the service is for. We saw that improvements in the Service User Guide include photographs, user friendly language and large print. Other formats are available on request. The manager said that each person has their own copy of the guide in their Care Homes for Adults (18-65 years) Page 15 of 34 Evidence: bedroom, but we asked one person who said they hadnt got a copy. We saw that the guide says that the cost of the bed space is £1005.52 per week, but we are not sure what this means. The range of fees for the service isnt documented in the guide nor is information for any additional costs. The manager said each person has a licence agreement but we saw from the example we looked at, that these are not up to date, therefore dont provide individuals with accurate information about the costs of the service. We would recommend that this information is up to date and in a user friendly format. Nobody has been admitted to the service in the last 12 months, but one person has been admitted since our last key visit. We looked at the records of this person to check that the admission procedures for the service had been followed, but couldnt find the information we needed to see. The manager showed us that multi disciplinary assessments had been sought and pre admission discussions had taken place. But we couldnt see if the individual had received an assessment from the service, had an opportunity to visit the service prior to deciding to move in, and if the service had confirmed with the individual that it could meet his needs. Care Homes for Adults (18-65 years) Page 16 of 34 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service have PCPs, planning their support and setting their goals. Evidence: The service told us in the AQAA that, Service users plans are developed using person centred planning principles in an easy to understand format and include decision making re mental capacity. Each service users plan is tailored directly to what assistance the service users wish us to provide, if this involves risk, the individual is supported to ensure participation in an active lifestyle. We use team reviews to gain a shared understanding of service users needs and look at outcomes for the service users using the 4 1 tool for creative outcomes. We also look at what is working and what can be improved in line with Person Centred Thinking to ensure the effective running of the home. We looked at the support plans of one person and spoke to another person about theirs. We saw that people have person centred plans in place, and have been told that they have been reviewed regularly. We saw that the information includes peoples goals and aspirations as well as their support needs. Care Homes for Adults (18-65 years) Page 17 of 34 Evidence: We saw that monthly summaries of each persons support are carried out. This information includes statistical information that can be used to assess improvements or to identify concerns. We couldnt tell from the information we saw if people are routinely involved with updates and reviews of their plans. We suggested that the service thinks of other ways in which people using the service can be included the development of their care plans and how they can take ownership of them. We saw that mental capacity information has been included in person centred plans this includes a statement and instructions that any decisions made on behalf of an individual should be made in their best interests. We spoke to the manager about one person who regularly states that they dont want to live at the home and advised that a Mental Capacity Assessment referral should be made, to be confident that the service is not depriving the individual of their liberty. We have been told that the service has reintroduced meetings for people who use the service to discuss things that are important to them and to become involved in making decisions in the home. The manager stated that the meetings will take place every three months. We spoke to people about their key workers they told us that they know who their key workers are and gave a positive account of their relationship and the support they receive. Risk assessments are in place and have been reviewed regularly. Care Homes for Adults (18-65 years) Page 18 of 34 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service make their own decisions about their lifestyle, and are supported to achieve their potential. Evidence: The service told us in the AQAA that, Service users are engaged in work with Choices, which they get paid for. One service user chats to new starters on their induction week, about his life and what he wants to do. All service users participate in activities that are suited to their age and choice, each individual has good links with the local community, such as butchers, local shops, barbers, newsagents, pub and cafes. One service user goes to his local church and is supported in accessing any events that are held at church or with the church. We encourage all service users to lead a varied and valued lifestyle based on their individual preferences, needs, wishes and choices. We looked at the person centred plan for one person, important things for this individual include having close contact with his family, but records show that this hasnt happened regularly recently. We spoke to the manager and a member of staff about this. We also Care Homes for Adults (18-65 years) Page 19 of 34 Evidence: looked at this person’s aspirations and goals which include going to watch a football team play. From the records of the person we case tracked, we saw that he is supported daily to go out of the home, shopping, walking, watching football matches etc. The service has just started to introduce a form to assess the peoples response to the activities they have been engaged in, this is intended to ensure that people are supported to be involved in activities that they choose, enjoy and benefit from. We saw that people in the home have a variety of social, recreational and occupational opportunities open to them. Including being involved with the local church and church group, some people have work placements with the organisation which we are told they are paid for. Four people using the service told us in surveys that, I like the food. They let you do drawing. They could make me more cups of tea. We saw that the service has continued to develop and review how people using the service are supported to live an active and independent lifestyle. People open their own post and have a key to the house and their own bedrooms. They are supported to be able to vote if they choose to and are supported to self advocate. We saw that people using the service are supported to prepare and make their own meals and drinks and have been told that, I help cooking the food if I want to. I like it and can have what I want. We saw that the service has a menu plan but have been told this is purely guidance, we saw evidence in other records that people are able to have food choices that are not included on the menu plan. Care Homes for Adults (18-65 years) Page 20 of 34 Personal and health care 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 using the service receive a service that meets their health and social care needs and their privacy and dignity are respected. Evidence: The service told us in the AQAA that, Each individual has a comprehensive package of health information. Health action plans and care plans continually monitored and reviewed for any health needs and support. Each individual also has a very detailed 24 hr plan of care which details specific support needed in all areas of the service users’ life. Staff have received training in the specific health needs of the service user and administering medication. Staff are inducted in to the home and receive training in the areas of personal and health care support. The service has told us it has made improvements since the last inspection visit such as, We now discuss testicular awareness with the men on a monthly basis. Introduced a pain tool for one service user. We have accessed OT for a bathing review for 2 service users and they have also assessed a service user for suitable equipment to help him to maintain his independence with shaving. All service users have a death and dying plan/will. We have written service users wishes re night time prompts in the support plans. The use of MAPA and PRN medication for challenging behaviour has reduced. A service user now administers his own 2pm medication at 9am (secondary dispensing if Care Homes for Adults (18-65 years) Page 21 of 34 Evidence: staff administer this medication), this enables him to be independent in the community and is in line with CQC guidance. We found that peoples health needs are recorded and Health Action plans are in place to ensure that their needs are met. We saw evidence of a multi disciplinary approach and working. In the records of the person we case tracked we saw involvement of a psychiatrist, psychologist, Occupational Therapist and social workers. There is also evidence in the records that people using the service are supported to attend health appointments including the GP, dentist etc. We looked at medication management in the service. We saw that we could not undertake an audit of medication received in the home that is not in the monitored dose system. This is because the quantity of medication received into the home has not always been recorded nor has the quantity of medication already in the home been carried forward. This means we couldnt be confident that the stocks of medication currently in the home is accurate. We saw that there are some examples when medication has not been signed for. We spoke to the manager about this. She stated that she had spoken to staff about this problem at a staff meeting and reminded them of the policy and procedures about safe administration and recording of medication. Care Homes for Adults (18-65 years) Page 22 of 34 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 using the service have access to an effective and accessible complaints procedure and can be confident that they are protected from potential abuse. Evidence: The service told us in the AQAA that, We have a clear complaints procedure which is visibly displayed in the home, for both service users and family members. We have an easy to read/pictorial complaints procedure for all service users to use. All staff are trained in recognising any signs of abuse and the correct actions to take if any abuse is suspected. All financial transactions are transparent and are backed up by a robust policy and record keeping. Complaints and compliments/abuse are agenda items on the team reviews and appraisals. Four people told us in surveys that they know how to make a complaint and who to go to if they have any concerns. We have not received a complaint about the service since the last key inspection visit. But the service has told us that it has received 4 complaints in the last 12 months, all have been resolved and not up held. We are aware that a referral under safeguarding procedures has been made regarding missing money, but we had to remind the service to do this. We are awaiting the outcome of any enquiries. A second referral has been made regarding a waking agency staff sleeping on nights. We saw that all staff have received training in recognising and reporting abuse and Care Homes for Adults (18-65 years) Page 23 of 34 Evidence: confirmed this with one member of staff we spoke to. We couldnt be sure that staff have received training or guidance regarding the Mental Capacity Act or deprivation of liberty and made this a recommendation. We looked at a sample of peoples financial records. Care Homes for Adults (18-65 years) Page 24 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service live in a safe and well maintained environment that meets their needs. Evidence: The service told us in the AQAA that, We provide a safe, comfortable and homely environment (but is adapted for service users who have a physical disability). The home is situated in an area which has plenty of amenities. It accommodates 8 gentlemen each of who have individual bedrooms decorated to their own tastes. Service users are involved in decision making re decorating. We support and encourage service users to produce grow flowers and their own vegetable and fruit in the greenhouse and vegetable patch. We have robust systems in place to control the spread of infection. All staff are trained in food hygiene, cross infection and COSHH. We have maintenance and repairs programme. We have also been told that improvements made since the last key visits include, purchasing more pictures and ornaments, redecoration of bedrooms and the living room and new flooring in the kitchen. The service offers accommodation for people in a two storey building that is divided into two flats. A ground floor and first floor flat, both for four people. All have single bedrooms but none have en-suite facilities. Separate bathing/shower and toilet facilities are Care Homes for Adults (18-65 years) Page 25 of 34 Evidence: provided. We saw evidence that the service is providing adaptations to the environment to meet the needs of people using the service. We discussed the proposal for a stair lift and have advised the service to contact fire safety services to discuss this further. Care Homes for Adults (18-65 years) Page 26 of 34 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. People using the service are supported by a staff team that are well trained, properly recruited and have the skills to meet their needs. Evidence: The service told us in the AAA that, We have sufficient appropriately trained staff. Training for staff is regularly updated. All staff have an agreed development plan. We meet the National Minimum Standards for the number of staff holding/doing the NVQ 2 in care qualification (currently 50 ) 2 staff are working toward the NVQ 2 and another 2 staff will commence October 2010. we induct staff on the General Social Care Councils code of conduct. We have a good relationship with Keele University and we have social work students and nursing students on placement at Community Drive. Staff have regular appraisal and support meetings. We have increased the staffing needs to accommodate service users changing needs. Roles and responsibilities are discussed at the team review yearly and at staff appraisals. We have had external training to meet the needs of the service users i.e. psychology, dietician and an update of MAPA is integrated into the team review. We received 7 staff surveys prior to the site visit, their comments include, The home always strives to work to best practise and is always conscious of our duty of care. But we could maybe more regularly meet to discuss peoples needs and update and feedback to people using the service and staff. Care Homes for Adults (18-65 years) Page 27 of 34 Evidence: We work well as a team, excellent work with clients and are able to talk easily with our manager. We need to always make sure we have enough staff and to offer a full range of activities and support our people to enable them to have a full and rewarding life. We could also employ more mid shift staff so we can go out more with people using the service. We provide a good range of activities. But could have more staff on so people using the service can go out when they wish and have more money. We are constantly reviewing how we implement a person centred approach and how we provide opportunities/experiences for people using the service. We saw that training records are maintained and that the service has a training plan. We looked at the training record of one member of staff and spoke to them about it. We looked at the recruitment records of two people and found them to be satisfactory. We spoke to one member of staff about induction and training. Care Homes for Adults (18-65 years) Page 28 of 34 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. People using the service can be confident that the service is well managed and has systems in place to ensure that the quality of the service they receive continues to improve. Evidence: The service told us in the AQAA that, The Registered manager and deputy are registered nurses for people with a learning disability; both have achieved the Registered Managers Award and the leadership and management course. We hold the Investors in People Award. We review accidents and incidents and follow these up as learning points at Team Reviews. We have a comprehensive and robust set of policies and procedures. We continually check the quality of the service. We set team targets and objectives. We monitor the performance of staff and we comply with all legislation designed to protect clients and staff from harm or injury. The manager has been registered and approved by us since the last key inspection visit. She stated that she has recently been allocated a deputy manager and hopes that this will ensure that the management of the service is robust. Care Homes for Adults (18-65 years) Page 29 of 34 Evidence: We received the AQAA when we asked for it and saw that it provided detailed information about the service, what it offers changes that have taken place and information about improvements it intends to make. Improvements since the last key visit include, We have re introduced service users meetings. We were regional finalists in the team category of the Great West Midlands Care Awards. A door guard has been fitted to the office door so that it can be kept open this encourages staff and people using the service to pop in when they want to discuss anything. We found that none of the recommendations made at the last key inspection visit have been addressed by the service, where we have found that they remain relevant we have included them as recommendations of this report. The manager told us that the organisation has won Gold Award status for Investors for people. We saw that the organisation has quality monitoring and assurance procedures in place, efforts are made to seek the views of people using the service and their relatives, but have not been extended to other stakeholders such as health professionals and other people who have involvement in the lives of people using the service. We saw that an annual action plan is developed from each quality audit. We have been told in the AQAA that equipment in the home is serviced regularly and that health and safety checks are carried out. We didnt look at this information during our visit but spoke one person about fire safety to ensure that they understand what to do in the event of a fire. We also saw that risk assessments relating to fire evacuation have been carried for each individual and are subject to regular review. Care Homes for Adults (18-65 years) Page 30 of 34 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 31 of 34 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 1 The provider should ensure that prospective users and user of the service have up to date information available to them about the costs and fees of the service. The provider should ensure that assessment information is available and that it can evidence that it has confirmed it can meet the needs of prospective users of the service. The service should ensure that people using the service take ownership of their person centred plans and feel in control of their lives. The service should make a referral for a mental capacity assessment where there may be concerns that a persons liberty maybe deprived. The service should consider how it can ensure that people using the service are actively included in decisions affecting their life. 2 2 3 6 4 6 5 6 Care Homes for Adults (18-65 years) Page 32 of 34 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 6 20 Medication administration records should be signed on each occasion medication is administered so that we can be sure that people using the service have received the medication they are prescribed. The service should ensure that it maintains accurate records of medication received in the home and medication carried forward, so that an audit trail of medication can be completed. The service should seek the views of people who are involved with the gentlemen from the community, to inform the quality audit about the ways in which the service could be further improved. 7 20 8 39 Care Homes for Adults (18-65 years) Page 33 of 34 Helpline: Telephone: 03000 616161 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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