Care Home: 16 Lumley Road

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What the care home does well The home supports people to lead busy meaningful lives and take part in the activities they enjoy. All care plans are reviewed regularly and are kept up to date to ensure that people have their needs met. The arrangements in place to meet the health care needs of residents are good and regular health checks are encouraged. Everyone that uses the service is happy and content with the support they are receiving. The manager has a very good understanding of each person`s needs and spends time working alongside staff to ensure they are competent in carrying out their roles. People that use the service have been given the information they need in order to make a complaint if they need to. The manager has spent time ensuring that people understand the complaints procedure and their care plans. The provider has a diversity policy that clearly states that people are treated fairly and no one is treated less favourrably because of something that is different about them. The manager and staff made it clear throughout the inspection how they welcome the differences in people and strive to tailor support around each individuals unique needs. What has improved since the last inspection? Some residents felt they could achieve greater independence and control over their lives by managing their own medication and personal allowances. The staff put in support plans, appropriate resources and undertook additional risk assessments to make this a reality. It is clear from observation and discussion with residents that the project has been successful in building confidence and self worth to a point where staff are only required to supervise people in achieving these tasks, rather than having to do it for them. Numerous environmental improvements have been made to the home which ensures that people living there are provided with a safe, homely and attractive place to live. The registered provider has shared information with staff in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards to ensure they are aware of their duties and responsibilities, and the service provides care and support for people who cannot take some decisions for themselves, in a way that complies with published codes of practice. What the care home could do better: Service users would benefit from all staff receiving updated infection control training . It was further recommended that the use of disposable paper hand towels in some additional areas of the home, would ensure infection control measures, designed to protect residents and staff, were not being compromised. The manager stated his firm intention to address this issue. Key inspection report Care homes for adults (18-65 years) Name: Address: 16 Lumley Road 16 Lumley Road Horley Surrey RH6 7JL     The quality rating for this care home is:   three star excellent 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: Marion Weller     Date: 0 8 0 6 2 0 0 9 This is a review of 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 2 1 0 stars - excellent stars - good star - adequate 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. 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. Care Homes for Adults (18-65 years) Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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) Copyright © (2009) Care Quality Commission (CQC). 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 CQC 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 29 Information about the care home Name of care home: Address: 16 Lumley Road 16 Lumley Road Horley Surrey RH6 7JL 01293782238 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: sivac@hotmail.co.uk www.mencap.org.uk Royal Mencap Society care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 6. The registered person may provide the following category/ies of service only: Care home only - (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). Date of last inspection Brief description of the care home 16 Lumley Road is a detached house developed to provide accommodation for up to six adults with learning disabilities. The home is set in a residential area within walking distance from Horley town centre. All bedrooms are for single occupancy and are decorated to a good standard. There is a pleasant garden to the rear of the property for service users and their visitors to enjoy. The home has some off road parking. The weekly fees for the home vary from £590 to £809 6 Over 65 0 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: The last key unannounced inspection of this service was completed on the 26th June 2007. This key inspection was undertaken on the 8th June 2009 from 12:05 am until 16:45pm. During the site visit the inspector spoke with four residents, two members of the support staff and the registered manager. The inspector was shown around the communal areas of the home and the rear garden by two of the residents and was also invited to view their individual bedroom accommodation. In addition, some records and documents were inspected. The inspection report takes into account all the information obtained about the service since the previous site visit. This includes any formal notifications, phone calls and letters received and any information concerning complaints or allegations. The manager was asked to complete the homes Annual Quality Assurance Assessment (AQAA) prior to the inspection. The AQAA is a self assessment that focuses on how well outcomes are being met for people using the service. It also gives some numerical Care Homes for Adults (18-65 years) Page 5 of 29 information about the service. The completed document gave us detailed and comprehensive information and provided a clear picture of what was happening in the service and plans for further development. Care Homes for Adults (18-65 years) Page 6 of 29 What the care home does well: 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 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 Care Homes for Adults (18-65 years) Page 7 of 29 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their representatives have access to all the information they need to enable them to make an informed decision about using the service. People moving to the home have an assessment of their needs and they are assured these will be met before they are offered a place at the home. Evidence: The home had an up to date Statement of Purpose and Service User Guide. People living in the home were aware of the Service User Guide and each had their own copy. The Service User Guide is presented in a user friendly format with pictures and symbols, is written in clear language and made available in large print. The homes Statement of Purpose gave more detailed information about the services provided at 16 Lumley Road and the structure of the home. The residents in the home have been living there for several years and there have been no new admissions. The manager described the assessment process they would follow for anyone new moving into the home. The explanation clearly followed good practice guidance. The pre admission assessment undertaken for two of the people already living there was seen and covered all the areas of support they needed. Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: Assessments had been updated regularly as part of the homes care plan review process. The residents living in the home are now becoming older. To recognise their changing needs, care plans are being reviewed monthly, in line with the national minimum standards for older people. Staff evidenced a good awareness of the needs of older people, which ensures people living there continue to receive a high level of support. Two residents told the inspector they felt their needs were being met and they had all had the support they wanted. Comments made by residents relatives or their representatives in the homes most recent quality satisfaction surveys also supported this view. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. Evidence: Each person has an individual plan of care. Two care plans were inspected in detail at this site visit. Person centred care plans, known as support plans at Lumley Road clearly showed that the resident had been consulted and involved in the formulation of the plan and that content was based on the persons full assessment of need. They were detailed documents, written in a user friendly format and covered all aspects of the individuals personal, social, and emotional needs. Reviews of individual support plans are now undertaken monthly due to the age of some of the people living in the home. Funding authorities also review care placements annually. Residents are being supported to make wider decisions in their lives, for example, where and how they wish to live in the long term and their future hopes and dreams. Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: The manager records in the homes AQAA that the service continues to focus on the promotion of residents independence and is taking the initiative to de register the home to provide supported living accommodation in line with the government white paper, Valuing People Now. In preparation for this move the manager explained a recent project to help four residents achieve greater independence and control over the lives by helping them to manage their own medication and personal allowances. The staff put in appropriate support plans and undertook risk assessments to make this a reality. They provided a safe and secure environment in which to support the aims of the project by providing lockable cabinets and cash tins in the residents bedrooms. A pictorial form of medication administration chart was formulated, so the people involved could safely identify the correct medication they needed at the correct time. The manager reports that the project has been very successful in building confidence and self worth, to a point where staff need only to supervise people in achieving these tasks, rather than having to do it for them. Residents explained their personal involvement in this project and evidenced their skills in administering their medication during the site visit and recording they had done so. Any restrictions to service users choices are managed through their personal support plans and risk assessments which are reviewed every six months and up dated regularly. Risk assessments were observed to be detailed and comprehensive and to adequately secure the individuals welfare and safety. The manager said they encourage relatives and other people who matter to the person to be involved in care planning meetings and reviews. Staff were knowledgeable about service users choices, needs and views and skilled in ensuring they were being met. Each service user has a named keyworker who works closely wih them. Most staff have completed training in person centred planning, which enables residents to take more control and ownership of their plans. In discussion residents evidenced high levels of satisfaction with the service and were keen and motivated to be involved in all aspects of life in the home. 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. People living in the home are supported to lead busy and interesting lives that meet they social and leisure needs. They are supported to identify and undertake their responsibilities in the home and their rights to privacy and personal space are respected. A varied and nutritious menu is available and people are supported to choose the meals they enjoy. Evidence: Residents are encouraged and supported to be as independent as possible and to make a choice about how they spend their time. Each has an individual written programme of activities designed to meet their needs. For example, during week days residents activities included working in local shops and a sales centre, attending day centres and a local gardening project, church activities, attending local clubs, shopping Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: and developing self help skills. In the evenings people are busy with a range of interesting and stimulating social activities, which includes attending local social clubs, cinemas and going to pubs and restaurants. During weekends visits may be made to local markets, boot sales, bowling and visits to neighbouring town centres. The home has a minibus, which is made available for residents use. The service also organises regular trips to the coast or other places of interest. Records in the home showed that activity plans are regularly followed. The manager records in the homes AQAA that residents finances are managed well and this enables the service to organise at least two holidays for people living in the home each year. One of the two is usually taken abroad. Since 2002 trips have been made to Portugal, Spain, Disney Land Florida, Greece, Paris and Canada. All residents spoke enthusiastically of their holiday experiences. One resident had also achieved a life long ambition to take a flight in a helicopter and showed the inspector souvenirs and photos of the event. Residents privacy in their own bedrooms is respected by staff. All residents have their own key to their bedrooms, lockable spaces and the front door of the home. Residents are encouraged to answer the front door to develop their independence and give them a sense of the property being their own home. Residents are supported to maintain contact with family and friends. Visitors are welcome in the home and some residents can arrange to invite friends for dinner if they wish. Family members and people from the local church regularly visit the home. The home provides transport facilities to take individuals to meet their relatives when they say they want to see them. One resident is able to travel by themselves to visit a relative at their home and spend weekends away with them. The menus are planned at house meetings and there is a good variety of nutritious meals offered. Each resident is allocated a day for cooking. The home has developed a pictorial form of food choices displayed on the board in the kitchen. There is a choice of breakfast, with a cooked breakfast available at the weekend. Residents make their packed lunch when attending activities and the main meal of the day is served in the evening. Food shopping is done locally and residents are encouraged to plan menus and help with the task. There is free access to the kitchen and drinks and snacks are available throughout the day. Some people can do this independently and others require some staff support. The manager stated that as the resident group at Lumley Road are ageing, they are regularly given nutritional advice during residents meeting and encouraged to add healthy options to menus they plan.The dietary needs of those residents with specific problems are carefully identified and regularly monitored and Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: nutritional risk assessment are in place. 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 excellent 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 their personal care needs met in the way they prefer and they are supported to be as self managing as possible. They have their health needs met through the primary healthcare team and the majority retains and administers their own medication. Evidence: Residents personal care needs are outlined in individual support plans. Health action plans have been introduced as recommended in the Valuing People white paper. This supports people to identify their own health needs in a holistic way and gives them more control over managing their health needs. Residents are encouraged to be as self managing as possible. Staff are aware of individual support plans and therefore residents receive personal care in the way they prefer and want. All residents are registered with a local GP and attend the surgery for appointments when required. Health records show that appointments are made and records kept regarding health care professionals involvement with residents. Chiropody is provided by a nearby practice and residents visit a local dentist regularly. On the day of the site visit one resident was supported by his key worker to visit the optician in the town. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: People are supported to dress in the way that promotes their self esteem and expresses their identity. They are supported to purchase their own clothes. There is a policy in place for the administration of medication and all staff receive training and they have ongoing competency assessments. Medication is provided by a local Pharmacy in blister pack format. The dispensing pharmacy also undertakes regular audits of medication within the home. Five residents are self managing with medication administration and as recorded elsewhere in this report, maintain their own medication administration records. The medication charts were seen for two residents and these are well maintained. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service know how to make a complaint if they need to and can be assured their concerns will be taken seriously. They are safeguarded in the home from harm and abuse. Evidence: The home has strategies in place to ensure that those who live there and those that visit can make their views and complaints known. The home records that it has received no formal complaints over the last year and minor concerns are dealt with quickly. There have been no safeguarding alerts or investigations in which the home has been involved over the last year. Residents said they knew how to complain. One resident said they would speak to the manager first or their key worker and if still worried, their care manager. Residents spoken with said they felt safe in the home and knew they had a right to report any concerns. There is a safeguarding adults policy in place and all staff undertakes training in adult protection issues during induction training. Staff spoken to were aware of safeguarding procedures and what action to take if they suspected abuse was happening. There is a copy of Surreys Multi Agency Policies and Procedures document for the Safeguarding of Vulnerable Adults in the home dated 2008. The manager and a senior support worker have attended the local authority training in safeguarding procedures and have cascaded this training throughout the staff team. Evidence further shows that robust recruitment procedures ensure that residents are protected Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: in the home. The manager records that one resident is included in the homes interview panel when they are looking for new staff. 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 home is clean and comfortable and meets the needs and preferences of the people that live there. Evidence: The home is kept clean, odour free and is maintained to a good standard of decor and repair. All residents bedroom are for single occupation and have been personalised to reflect the tastes and the interests of the occupants. Three people showed the inspector their bedrooms and said they had everything they needed and they were happy with their rooms. There is a large lounge and dining room for residents to use and the kitchen is accessible to the people living in the home. There is a large garden to the rear of the home, which is well maintained and used by the residents. There are sufficient bathrooms to meet peoples needs with a mixture of baths and showers. Liquid soap was in evidence in toilets however, a communal cotton hand towel was provided for people to dry their hands in the ground floor toilet. It was recommended that the use of disposable paper hand towels would ensure the homes infection control policy was not compromised. The manager stated his firm intention to address this issue. Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: The manager spoke of numerous environmental improvements made to the home. For example, the aged tiles to the downstairs communal toilet were replaced. Three residents had new carpet laid in their bedrooms. The communal areas were all redecorated and new curtains were purchased for the lounge and the dining area. The upstairs bathroom and flooring was replaced. 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. Residents benefit from a competent and qualified staff team who are properly supervised in their work. They would benefit further from more staff having received updated infection control training. Residents are protected in the home by robust recruitment practices. Evidence: Two staff files were seen and these contained all the necessary documentation to evidence that appropriate checks had been made before employing people to work in the home. This included obtaining two written references, a health check and a criminal records check. All staff complete an application form, stating their job history, and undergoes an interview. The manager said that a service user is involved with interviewing new staff. The home could evidence that over 50 of staff employed are NVQ qualified, at either levels 2 or 3. Staff training records showed staff have completed the mandatory training courses they need to carry out their roles safely and to meet the specific care and health needs of people living in the home. A relative recorded in the homes recent quality assurance survey......Staff are always friendly and professional. Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: The providers training department also provides distance learning packages, so that staff can upgrade their knowledge and skills by accessing the homes office computer and completing training exercises on-line. Training plans viewed did not however evidence arranged dates for infection control training for staff during 2009/10. The manager stated that he and a senior carer had previously attended the Health Protection Agencys health and safety course, which covered infection control matters. The manager stated his firm intention to arrange the training discussed to address the shortfall. Staff have regular supervision with the registered manager and records evidence that supervision covers many areas of their work, practice and responsibilities in the home. The manager explained that supervision sessions and staff meetings are also used as a means of updating staff with any changes in legislation and good practice guidance. The manager spoke particularly about the demands that The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards had made on the homes practice recently. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home benefit from a competent and experienced manager who runs the home in their best interests and in addition, they are being regularly consulted on their views about the care they receive. The health and welfare of service users is protected and they can be confident that where minor shortfalls exist, such as in current infection control measures, these will be addressed quickly by the manager. Evidence: The registered manager has worked at 16 Lumley Road for 14 years and demonstrated an excellent understanding and insight into the individual needs of the people living in the home. Residents spoken with said they liked the manager and felt they could always talk to him or the other staff if they had any concerns. The manager evidenced that he is suitably qualified and sufficiently knowledgeable to effectively run the home on a day to day basis and has the best interests of service users at the core of service delivery. In relation to The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, assessments of capacity and decision making for residents are Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: being undertaken in a way that complies with published codes of practice. There is no one living in the home who is the subject of a deprivation of liberty authorisation. Quality assurance surveys are sent out to service users, relatives and other stakeholders in the service annually. The most recent surveys were completed in May 2009. These clearly showed that people are happy and content with the service they receive. Comments included....The manager is always friendly, welcoming and very caring and works hard for the residents. And.....The manager is excellent. Relevant risk assessments have been completed for the home and a fire risk assessment is in place. There were no significant issues regarding health and safety, although service users would benefit from staff receiving updated infection control training and it was recommended that the use of disposable paper hand towels would ensure the homes infection control policy was not compromised. The manager stated his firm intention to address this issue to safeguard residents from any potential for harm. 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 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!