Care Home: 17 Wheatfield Drive

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What the care home does well It is evident through us talking to members of staff that the emotional health of the residents is of a high priority to the home and that staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life in accordance to their plan of care. Staff demonstrate their commitment to achieving best outcomes for residents. Staff stated they expressed job satisfaction and confidence in the management of the home. Residents who spoke to us confirmed in their own words that they receive a good quality of care from staff who are courteous, respectful, communicate well, are experienced and deliver care in a individualised and professional manner. Observation of interaction between staff and residents throughout the visit confirmed that privacy and dignity is respected in the home. Many comment cards received about the home reflected a very positive experience of the home and further evidenced that the home works towards providing a high level of care. What has improved since the last inspection? It was evident through the inspection process that the home has taken steps to improve the standards of care and has actioned the recommendations made within the previous inspection. What the care home could do better: Some recommendations were made to improve the service provision. Outcomes for the quality of care are good. However shortfalls identified within this report with regard to staffing potentially put residents at risk and limits opportunity for one to one support. The Commission recommended that staffing is reviewed. The manager is aware of the shortfalls and has indicated a willingness to work with the Commission to address these issues. The home has a limited quality assurance system. Quality monitoring systems do not currently provide management evidence that practice reflects the homes policies and procedures. No requirement has been made at this time as the Commission is confident that any shortfalls will be addressed. An appointed person of the registered provider of the home does not regularly visit the home and complete what is known as a Regulation 26 visit, the last visit was March 2009 which was carried out by an individual who did not have the experience or qualifications to make a judgement on the quality of care within the home. Evidence to make this judgement was made following discussions with the deputy manager and last reports seen. The Regulation 26 visits requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. This was seen as a shortfall and could compromise the quality of the care provided by the service due to lack of a robust quality assurance process within the home. Key inspection report Care homes for adults (18-65 years) Name: Address: 17 Wheatfield Drive 17 Wheatfield Drive Cranbrook Kent TN17 3LU     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: Robert Pettiford     Date: 2 1 0 7 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 27 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 27 Information about the care home Name of care home: Address: 17 Wheatfield Drive 17 Wheatfield Drive Cranbrook Kent TN17 3LU 01580240118 01580240270 cg-@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Linda Joyce Fennell care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is 3. The registered person may provide the following category 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 17 Wheatfield Drive is a detached, modern house situated in a residential area of Cranbrook. The home provides care for up to three residents. All bedrooms are single occupancy. There is a spacious lounge and separate dining room for residents use. The Registered Provider also owns a similar house next door. Limited parking is available to the front of the premises and some parking is available in the road. There is a wide range of services in the town including shops, pub, church and the police station is next door. 3 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The inspection took place at 9:00AM on 21st July 2009 We agreed and explained the inspection process with the registered manager who was present for part of the inspection and the deputy manager. The focus of the inspection was to assess the home in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, pre inspection information such as the previous report and discussion and correspondence with the registered provider/manager was used in the planning process. This was to support us to explore any issues of concern and verify practise and service provision. Care Homes for Adults (18-65 years) Page 5 of 27 The home had completed an annual quality assurance assessment questionnaire (AQAA). This provided us with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Commission to be able to make an informed decision about outcome areas. Further information can be found on the Commissions website with regards to information on KLORAs and AQAAs. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, rotas, and training records. In addition an environmental tour took place. We identified a sample of residents for case tracking (a review of the level of care and support needed, and if it is being provided in a way that treats them with respect and dignity). Care Homes for Adults (18-65 years) Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: Some recommendations were made to improve the service provision. Outcomes for the quality of care are good. However shortfalls identified within this report with regard to staffing potentially put residents at risk and limits opportunity for one to one support. The Commission recommended that staffing is reviewed. The manager is aware of the shortfalls and has indicated a willingness to work with the Commission to address these issues. The home has a limited quality assurance system. Quality monitoring systems do not currently provide management evidence that practice reflects the homes policies and procedures. No requirement has been made at this time as the Commission is confident that any shortfalls will be addressed. An appointed person of the registered provider of the home does not regularly visit the home and complete what is known as a Regulation 26 visit, the last visit was March 2009 which was carried out by an individual who did not have the experience or qualifications to make a judgement on the quality of care within the home. Evidence to make this judgement was made following discussions with the deputy manager and last reports seen. The Regulation 26 visits requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. This was seen as a shortfall and could compromise the quality of the care provided by the service due to lack of a robust quality assurance process within the home. Care Homes for Adults (18-65 years) Page 7 of 27 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 order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 27 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 27 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. Residents can be confident that their needs will be properly assessed prior to moving to the home. Evidence: The previous inspection and records held showed that residents have an assessment which identifies their individual needs prior to or on admission to the home. The information is provided by the residents, their families and health / social care professionals. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet needs of the individual. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Prospective Residents have the benefit of a trial period to assess whether the home can or cannot meet their needs. The AQAA also confirmed information with regard to ensuring that the home can meet Care Homes for Adults (18-65 years) Page 10 of 27 Evidence: the needs of residents. The assessment process as shown in the AQAA recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. Care Homes for Adults (18-65 years) Page 11 of 27 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. Residents benefit from having clear individual plans that are comprehensive, identify their needs and are specific to the individual resident. Evidence: The key principles of the home for delivering a quality service are based on the belief that residents should be able to take control of their lives. The staff of the home are strongly committed to supporting all residents including those with limited communication or learning disabilities to make informed decisions, understand the range of options which are available to them and have the right to take responsible risks. Evidence of this was gathered through taking to the residents, staff, manager and information contained in the AQAA. The home and its staff are committed to supporting the residents. This was evidenced through the care plans which detailed the areas of support that the resident needed and how this support is provided by the staff. Care Homes for Adults (18-65 years) Page 12 of 27 Evidence: There were guidelines in respect to routines and behaviour. The member of staff confirmed that these are reviewed with the residents on a regular basis and the families are supported to be involved. The plan focuses on current needs, development of skills. This follows the principles of person centred planning. Staff have the necessary training and skills to support and encourage the individual to be fully involved. Where Residents have limited communication, staff are skilled in using other methods of engagement. A key worker system provides additional support enabling one to one involvement. Residents rights to make decisions are respected and the care plans reflected their ability to make an informed judgement. Plans sampled demonstrated that the home used positive planned interventions to manage residents behaviour. Care plans included risk assessments. All areas of risk were identified in the documentation viewed. Management of risk takes into account the specialist needs and age of people who use the service, balanced with their aspirations for independence, choice and normal living. Where there are limitations on choice or facilities, it is in the persons best interest. The resident understands and agrees the limitations where possible. Care Homes for Adults (18-65 years) Page 13 of 27 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. Residents can be confident that they are offered a range of opportunities for personal development and to learn new skills and feel part of the wider community. Residents engage in a good level of activities which are appropriate to their needs and capabilities. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered at the home. Evidence: Residents are enabled to participate and contribute to meeting their own self care Care Homes for Adults (18-65 years) Page 14 of 27 Evidence: needs and day to day chores around the house. Discussion with residents and staff confirmed that the level of activities were of a good level and that they enjoyed a good level of stimulation through leisure and recreational activities both inside and outside the home. We joined residents at 9:00am while they were getting ready for the day ahead. Residents were observed participating and interacting with staff. Residents have been enabled to and encouraged to participate in hobbies and activities which they had an interest in, such as maintaining and building on personal collections and specific recreational activities. The service actively encourages and provides imaginative and varied opportunities for Residents to develop and maintain social, emotional, communication and independent living. However limited options are available for one to one activities without forward planning. The home was reccomended to review its staffing levels to aide more flexability and one to one support. The staff have a strong ethos and focuses on involving Residents in all areas of their life, and actively promotes the rights of individuals to make informed choices. The AQAA showed that residents are encouraged to use all aspects of their home according to their ability and wishes - these include laundry, cooking, cleaning and gardening. Residents are encouraged to pursue activities, hobbies and interests both inside and outside of the home. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. Residents were consulted with regard to whom they saw and when and were under no compulsion to accept visitors should they not wish to do so. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the residents activities and schedules. Residents are able to choose where to eat, and also have facility to make drinks, meals and snacks for themselves and others with staff support should they wish. Residents on evidence seen have had been involved in planning and choosing what to eat. Care Homes for Adults (18-65 years) Page 15 of 27 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. Residents feel supported by the level of help given and that their healthcare needs are addressed. Residents can feel confident that their wellbeing will be protected by the homes policy and procedures with regard to the handling and administration of medication. Evidence: The care plans fully documented the personal support required for individual Residents within 17, Wheatfield Drive. They reflected their choices and preferences and staff were observed offering guidance where needed. Times of getting up / going to bed, having baths, eating meals and other activities are flexible to allow for different Residents daily routines. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents. It is recognised that the delivery of personal care is highly individual and must be flexible, consistent and reliable. Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to changing needs of residents. Residents are supported Care Homes for Adults (18-65 years) Page 16 of 27 Evidence: and helped to be independent and responsible for their own personal hygiene and personal care. The care plans also fully documented all physical and emotional health care needs and where able Residents filled in or were supported to fill in appropriate forms. Within the care plans records of health care provided by G.P, chiropodist, dentist, and opticians was evident. Residents physical and emotional health is monitored on a daily basis. Through their daily records and these correspond with support assessments held in the care plans. This system ensures that all Residents receive continuity of care and supports potential complications and problems at an early stage. It is evident through records that the emotional health support is of a high priority to this home and the staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. Evidence to support the judgements made within this section have been obtained within the AQAA and discussions with the residents, manager and staff. We viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of PRN/As Required Medication. The medication was seen to be stored appropriately and administered in accordance to current guidance. Some recommendations are made with regard to ensuring any additions to the MAR sheets are double signed The manager confirmed that all staff who dispense medication have received appropriate training. The home now has a medication policy which meets with the recommendation made at the previous inspection. Care Homes for Adults (18-65 years) Page 17 of 27 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. Residents know that their concerns and complaints are taken seriously and are protected from the risks of abuse. Evidence: A copy of the complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. The complaints procedure is highly visible within the service and is more readily available in different formats. The procedure however needed updating as it referred to the Care Quality Commissions previous legacy organisation. No complaints have been recieved by the Commission or adult abuse alerts made since the last inspection. The homes Policy for the Protection of Residents and staff Whistle blowing procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training is provided adult protection. The home promotes an open culture where Residents feel safe and supported to share any concerns in relation to their protection and safety. Policies and procedures regarding protection are in place. Any referrals made have been dealt with appropriately and were well managed by the home. Care Homes for Adults (18-65 years) Page 18 of 27 Evidence: The home ensures through training, review and quality monitoring that care staff fully comply with the policies and procedures provided in relation to protecting and safeguarding the rights of people who use the service. Staff spoken with had a good understanding of abuse and how to address it should it be evidenced. Care Homes for Adults (18-65 years) Page 19 of 27 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. Residents benefit from living in a clean comfortable home, which is suitable for their needs. Evidence: It was apparent that the individual and collective needs are being met in a comfortable environment. The standard of internal decoration and fixtures and fittings are well maintained and of a good quality. The home benefits from a selection of communal areas thus affording residents space should they so wish or desire. Plans are also in place to update one of the bedrooms. The premises are kept clean, hygienic throughout and systems are in place to control the spread of infection. The laundry facilities currently meet the needs of the residents living within the home. Care Homes for Adults (18-65 years) Page 20 of 27 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 care, social and emotional needs are promoted by the employment of caring and suitably trained staff. Evidence: From discussions with the manager, observations and reviewing the staff rotas sufficient staff were on duty at the time of inspection to meet the residents imediate needs. However limited options are available for one to one activities without forward planning. The home was reccomended to review its staffing levels to aide more flexability and one to one support, and ensure the health and safety of staff working on their own. The staff training records indicated planned and undertaken training. The manager evidenced that individual and group staff training needs had been identified. A wide range of training has been identified for all staff . The manager present confirmed that the induction programme adopted complies fully with the recommendations of the Skills for Care Councils current guidance. The staff training records indicated planned and undertaken training in all the key Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: areas. Core training in Infection control, Moving and Handling, Basic Life support, fire training, food hygiene, and Adult protection has been provided. Core courses are undertaken by staff to maintain current qualifications and for protection of residents. However not sufficicient numbers of staff being 50 have achieved NVQ qualifications in Care to level 2 or above. The manager is aware of this shortfall and additional staff are registered to start NVQ training to address this shortfall. Care Homes for Adults (18-65 years) Page 22 of 27 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. Residents benefit from living in an overall well run and managed home. However lack of a robust quality assurance process could comprimise the quality of care within the home. Residents and or their relatives can be fully confident that their views and opinions effect how the home is run and that their best interest are safeguarded by appropriate policies and procedures. Residents can always feel fully confident that their health and safety/ welfare is protected by robust policies/ procedures and safety checks. Evidence: The registered manager is actively involved in the day-to-day management of the home and works with staff and residents. However her time within the home is limited due to her currently additionally managing another home owned by the provider. She has indicated her wish to de register and the current deputy will put herself forwards for registration. The deputy stated her intension to become suitably qualified and is Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: intending to start the relevant care and management qualifications shortly. Outcomes for the quality of care are good. However shortfalls identified within this report with regard to staffing potentially put residents at risk and limits opportunity for one to one support. The Commission recommended that staffing is reviewed. The manager is aware of the shortfalls and has indicated a willingness to work with the Commission to address these issues. Residents expressed a great deal of satisfaction of the care provided and the staff are very supported of the manager and have a positive ethos. From observation and staff feedback the manager offers a clear sense of direction and leadership, which staff and residents understand. Residents, their relatives and staff are encouraged to comment on the services the home offers and to voice any concerns they may have. The home has a limited quality assurance system. Quality monitoring systems do not currently provide management evidence that practice reflects the homes policies and procedures. An appointed person of the registered provider of the home does not regularly visit the home and complete what is known as a Regulation 26 visit, the last visit was March 2009 which was carried out by an individual who did not have the experience or qualifications to make a judgement on the quality of care within the home. Evidence to make this judgement was made following discussions with the deputy manager and last reports seen. The Regulation 26 visits requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. This was seen as a shortfall and could compromise the quality of the care provided by the service due to lack of a robust quality assurance process within the home. No requirement has been made at this time as the Commission is confident that any shortfalls will be addressed. The home has a full range of policies and procedures to promote and protect residents health and safety. Staff consistently follows these. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. There is a understanding of risk assessment and this is taken into account in all aspects of the running of the home, however the environmental risk assessment had not been updated. The residents spoken with confirmed a great deal of satisfaction living within the home and felt confident that their views and opinions were valued by both staff and management. Care Homes for Adults (18-65 years) Page 24 of 27 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 25 of 27 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 26 of 27 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 27 of 27 - 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!