Care Home: 19 Haymill Close Short Break Service

Similar services:

• Ashlong House
• Norbury Crescent (30)
• Edenvale
• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Chatsworth Care - Tudor Lodge
• Foxley Lane (121a)

What the care home does well People who are referred to the service are fully assessed and given the opportunity to visit as often as they need to before using the service, in order to ensure the service can meet their needs. The service user plan documentation is clear and comprehensive, providing a good picture of each person, their needs and how these are to be met. Risk assessments are in place for all identified risks, to show how these are best managed for each individual. People using the service are supported to maintain as much independence as they can whilst they are there. Each person has an individual activities programme, and the service ensures that it facilitates people to continue with their activities whilst using the service. The home has an open visiting policy and visiting is encouraged. Staff have a good knowledge of the people in their care and provide support in a friendly and professional manner, respecting privacy and dignity. The food provision at the service is good and is tailored to meet the dietary and cultural needs of the people using the service. Protocols are in place to ensure that the healthcare needs of people using the service can be met to maintain their wellbeing to the optimum level. Staff have the experience and understanding to communicate effectively with people using the service. Medications are being well managed, with some recommendations made to further enhance medication management. Clear procedures are in place for the management of complaints and safeguarding adults issues, and these are adhered to, thus protecting people using the service. Overall the home is being well maintained, providing a clean and homely environment for people to stay in. Infection control procedures are in place and are being adhered to. The service is being appropriately staffed to meet the needs of of people using the service. Staff vetting and recruitment procedures are robust and are followed, thus safeguarding people using the service. Staff receive the training they need to provide them with the skills and knowledge to care effectively for the people who use the service. The management team has the skills and experience to manage the home effectively, and cover for leave is planned in advance to maintain continuity of management at the service. Systems are in place for quality assurance and the service is aware of further developments in this area that will facilitate people using the service to feed into improvements to be made. Health and safety is being well managed at the home, thus protecting people who use the service, staff and visitors. What has improved since the last inspection? This is the first key inspection since the home registered in July 2009. What the care home could do better: Some of the risk assessments had not been reviewed, and even if there is no change to the assessment there should be evidence of review as a matter of good practice. We have made some recommendations to enhance medication management within the home. The lounge and dining areas are in need of redecoration, and this is being planned for. Key inspection report Care homes for adults (18-65 years) Name: Address: 19 Haymill Close Short Break Service 21 Haymill Close Perivale Greenford Middx UB6 8HL     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: Clare Henderson-Roe     Date: 1 9 0 1 2 0 1 0 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 26 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 26 Information about the care home Name of care home: Address: 19 Haymill Close Short Break Service 21 Haymill Close Perivale Greenford Middx UB6 8HL 02085667060 02088109531 hm19sbs@supportforliving.co.uk www.supportforliving.org.uk Support for Living Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Miss Annabelle Lambourn Type of registration: Number of places registered: 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 - code PC to service users of the following gender: Either whose primary needs on admission to the home are within the following categories: Learning Disability - Code LD Date of last inspection Brief description of the care home 19 Haymill Close Short Break Services was registered in July 2009, to provide short break services for a maximum of 3 people at any one time. The home was originally registered together with number 21 Haymill Close, and has been offering a short break service for some years. It is owned by Support For Living and all people who use the service are referred by Ealing social services Community Team for People with Learning Disabilities. The home is situated on a housing estate and there are 3 other Care Homes for Adults (18-65 years) Page 4 of 26 Over 65 3 3 Brief description of the care home homes in Haymill Close also owned by Support For Living. The home has 3 bedrooms, a lounge, a dining room and a kitchen, plus toilet and assisted bath facilities are available. There is also a garden available, and there is space nearby for on street parking. The home is near to the A40 and a short walk from bus links to Ealing Broadway and Greenford. Ealing Broadway station provides both tube and rail links. Care Homes for Adults (18-65 years) Page 5 of 26 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: This was an unannounced inspection carried out as part of the regulatory process. A total of 4.5 hours was spent on the inspection process, which included a tour of the home and viewing records to include medication management, service user plan documentation, training records, quality assurance documentation, staff employment record information and maintenance and servicing records. The Annual Quality Assurance Assessment (AQAA) completed by the Service Manager has also been used to inform this report. We spoke with 1 person using the service and 5 staff. No visitors were present at the time of inspection. Care Homes for Adults (18-65 years) Page 6 of 26 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. Care Homes for Adults (18-65 years) Page 7 of 26 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 26 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 26 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. All people who are referred to the service are fully assessed and have the opportunity to visit the home and feel comfortable about being there before respite care is arranged, in order that they can get to know the home, staff and other people who use the service. Evidence: People are referred to the service via social services. A copy of the assessment carried out by the Community Team for People with Learning Disabilities (CTPLD) is provided to the home and a comprehensive assessment is also carried out by Support For Living (SFL) so that they have an up to date picture of the person to use the service, their needs and circumstances. All people referred to the service visit for a few hours with their carers initially and then spend some day time at the home with the staff before overnight stays are planned, in order that they can get to know the home and some of the other people who also come to stay, and feel comfortable about being at the home. Care Homes for Adults (18-65 years) Page 10 of 26 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. Service user plan documentation is comprehensive and up to date, providing staff with a good picture of each person, their individual needs and how these are to be met. People using the service are encouraged to maintain their independence as much as they are able. Risk assessments are in place for all identified areas of risk, to minimise risks to individuals, however regular reviews need to be done for all risk assessments to ensure they are kept up to date. Evidence: There is a Personal Care Support Plan in place for each person using the service and this provides a good picture of the individual and how their needs are to be most effectively met. There is also a service user profile sheet, which contains a photo and in one page provides up to date information about several aspects of the persons life and care. This information is also backed up with an individual care file, containing historical information about each person. The people who use the service are encouraged to express what they would like to do Care Homes for Adults (18-65 years) Page 11 of 26 Evidence: when at the home, and information about each persons daily and weekly routines is contained within each persons care records. There is a notice board with pictures of the staff on duty for ease of identification by residents. Risk assessments were available covering all identified areas of risk for each individual. Some of the people have been using the service for some years, and we noted that although the risks may not have changed, the reviewing of risk assessments as a matter of good practice had not always been carried out. In a second care file viewed there was evidence that there had been a recent review of all the risk assessments, and the Service Manager stated that SFL themselves had identified the need to ensure all risk assessments are kept under review and are in the process of addressing this. Care Homes for Adults (18-65 years) Page 12 of 26 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. There is an individual activities programme for each person and the home works to ensure the programme is met. The home has an open visiting policy and visitors are welcomed. Staff have a good knowledge of the people who stay at the home, supporting them with care needs and respecting their privacy and dignity. The food provision at the home offers variety and choice to meet each persons dietary needs. Evidence: The following quote is taken from the AQAA for the home: We support the people living at the service to pursue activities of their choosing whilst maintaining their health and well being. We offer opportunities to pursue a variety of activities including Social clubs, cinema, cafes and pubs, parties, day centres, churches, parks, museums and galleries. We also offer activities at home such as music, TV/DVD and massage sessions. Similarly we encourage and support the service users to be involved in all aspects of their own life including domestic jobs such as cooking and cleaning. Service Care Homes for Adults (18-65 years) Page 13 of 26 Evidence: users are supported to see their friends or family where this is possible. There is a vehicle available for use at the service and service users are also encouraged to use public transport and can take advantage of schemes, such as taxi cards. We saw evidence of activity programmes being in place, with some updating to be carried out, however up to date information about activities was available on the service user profile document. Staff are available to go out with people staying at the home so that they can enjoy outdoor activities in the community. The home ensures that people are taken to and from daily activities such as attendance at day centres and college. The home has an open visiting policy and visitors are welcomed at the home. The home provides short break services to provide respite care and people staying at the home meet up with their families when being collected from the service, however visiting is encouraged also. We observed good interaction between staff and a person staying at the home, who appeared content and well cared for. Staff have a gentle and caring attitude and those spoken with had a good knowledge of the individual care needs of the people who stay at the home and the importance of making them feel welcome and valued. The home has a menu that is tailored to suit the dietary needs and preferences of the people staying at any one time, and the ethos is on the provision of a healthy and balanced diet. The menu is planned week to week, so that people have input into the days or nights they will be staying at the home. There was a good supply of foodstuffs available in the kitchen and it was all being stored appropriately. Care Homes for Adults (18-65 years) Page 14 of 26 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. Individual healthcare needs are known to staff at the home, and where necessary medical intervention is arranged, thus helping to maintain each persons optimum level of health. Medication management is good, thus ensuring that people receive their medications as prescribed. Evidence: The following information is taken from the AQAA: At 19 Haymill Close we support individuals during the time that they are staying at the service. However, we like to think that as a service we will engage in supporting individuals and families through a multi agency approach. Where possible we have assisted to support individuals families when at hospital for example. If we had any particular concerns we would communicates these to the relevant people and primary carers and keep written reports of such incidents. Some of the service users need medication and our staff are trained accordingly in administering and storing medications correctly. The home has worked to ensure that the staff mix at the home meets the needs of the people who stay at the home, to include meeting cultural needs, plus the gender preference of each person for assistance with personal care. Staff spoken with Care Homes for Adults (18-65 years) Page 15 of 26 Evidence: understood the needs of the client group, and also were able to explain how they ensure they communicate effectively with people who stay at the home. The home has people staying on short term respite placements. The home has information such as each persons medical diagnosis and medication record. Medical intervention is arranged as part of their care for maintaining optimum health at home. Should someone become ill when in respite care, then action would be taken to get medical assistance, to include emergency care. The home does liaise with the CTPLD in order to obtain a good picture of each persons needs, to include medical needs. We viewed medication records and management. The service user profile document includes a photograph, each persons diagnosis and list of their medications. A list of staff signatures and initials for all staff administering medications was available. There is a printed medication administration record (MAR) for each resident, and these are completed for all medications administered for the period of time the person is in the home. We noted in one instance the dose of a medication had changed and this had been altered on the MAR. We recommended re-writing the whole entry in order to ensure that the change of dose is clearly identified. Medications are supplied by the family and a clear record of all medication received from and given back to the persons representative is maintained. Should there be a need for a medication to be left at the home, then we discussed dating the bottle on opening as good practice, so that there is a clear record of opening and medications can be disposed of once it has reached the expiry time for opened medications. Medications were being securely stored at the home and overall medications are being well managed. Care Homes for Adults (18-65 years) Page 16 of 26 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. The home has clear complaints and safeguarding adults policies and procedures in place, and these are followed, thus protecting people who stay there. Evidence: The following information is taken from the AQAA: We liaise closely with the learning disabilities team at Green Lane and communicate any concerns, complaints, incidents/accidents and SoVA (Safeguarding of vulnerable adults) issues with them if they arise. We complete comprehensive and detailed paperwork and fax and share this with relevant people. The home has a clear complaints procedure and this is available in easy read format. A copy is given to everyone who is assessed for accessing the service. The home has not had any complaints in the last 12 months. There is also a safeguarding adults policy and SFL also follow the Ealing safeguarding adults protocols. There had been one safeguarding adults incident and this had been reported and correct procedures followed. Staff spoken to were very clear to report any concerns and confirmed that they receive safeguarding adults training as part of the induction programme. The home will hold £5 cash on behalf of each person, and there are clear records of receipt of monies and expenditure maintained. There is a monies record book for each person who uses the service and this is audited twice a day. Receipts are available for all expenditure. Care Homes for Adults (18-65 years) Page 17 of 26 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 being maintained to provide a comfortable, homely environment for people to stay in, with some additional decoration work to be done to further enhance the home. Infection control procedures are in place and are adhered to, thus minimising the risk of infection for people using the service. Evidence: We carried out a tour of the home. Overall the home is being maintained and provides a comfortable and homely environment for people to live in. The lounge and dining areas were in need of redecoration and the Service Manager was aware of this. Other areas were in good condition and the furnishings throughout the home are of a good standard. There are 3 bedrooms, one of which has sensory equipment installed that can be used to provide relaxation therapy for people who stay at the home. Bedrooms also have TV and radio facilities, and playstations are also available on request. There are assisted bath and toilet facilities available. The bathroom door had been damaged and was in the process of being repaired, however a curtain had been provided to maintain peoples privacy until the door was replaced. The Service Manager said that all the people using the service are mobile so the home does not need moving and handling equipment at this time. The home has a garden and according to the AQAA there are plans to enhance the garden facilities to make them more accessible to people using the service. Care Homes for Adults (18-65 years) Page 18 of 26 Evidence: There is a laundry room and staff explained that laundry is carried out separately for each person using the service. A list of clothing is compiled for each visit and the home does request that clothing is labelled. Protective clothing to include gloves and aprons was available and the home also has clinical waste facilities. Laundry guidelines and universal infection control policies and procedures were on display in the laundry. The home was clean and fresh throughout. Care Homes for Adults (18-65 years) Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels are based on the needs of each person using the service, to ensure their needs can be met at all times. Systems for vetting and recruitment are in place and are adhered to, thus protecting people who use the service. Staff receive training to provide them with the skills and knowledge to care effectively for people who use the service. Evidence: The following information is provided in the AQAA: The managers and staff team are very committed at 19 Haymill Close. The recruitment is such that the service has attempted to ensure we have a varied and skilled team that match the needs of the service users who come to stay at 19 Haymill Close. The training of our staff at 19 Haymill Close is significant and has included service specific training to enable staff to support people to a high standard. All new staff undergo a 6 week induction training programme, followed by 2 weeks induction in the home they are to work in. Following this they commence NVQ in care level 2 training. In addition staff also undertake training specific to meet the needs of people with learning disabilities and one new member of staff is doing the Learning Disability Qualification. Of the other 9 permanent staff, 6 are qualified to NVQ level 2 or 3 and 3 are undertaking level 2. Staff spoken with said that there is a good amount Care Homes for Adults (18-65 years) Page 20 of 26 Evidence: of training provided by SFL and the training does provide them with the knowledge and skills to care for the people who use the service effectively. The training matrix evidenced the training undertaken and planned and the mandatory training includes health and safety topics plus choking, resuscitation, and safeguarding training. The staffing levels for the service are based on the needs of the people staying at the service at any one time. The assessments carried out before a person starts to use the service include the staffing level needed for each individual. The home has a weekly respite bookings chart which covers 24 hour care needs. The staffing roster reflects the staffing levels required for each person during the day, which is a ratio of 1 or 2 staff to each person using the service. There is one waking night staff and one sleepin on call night staff every night. Additional night cover can be arranged should it be needed. SFL hold all the staff employment information at head office, and provide the home with an employment profile, which lists the all the pre-employment checks carried out in line with Schedule 2 of the Care Homes Regulations 2001. The manager was not available at the time of inspection to give access to these records, however the Service Manager was able to provide copies of the forms and confirm that the originals would include a photograph. There were photographs of the staff on display in the home. Care Homes for Adults (18-65 years) Page 21 of 26 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being effectively managed, with clear arrangements in place to provide continuity of management for the service. Systems are in place for quality assurance to provide an ongoing process of review and improvement. There are good systems in place for the management of health & safety, thus protecting people using the service, visitors and staff. Evidence: The registered manager has the skills and experience to manage the service effectively. She was on annual leave prior to maternity leave at the time of inspection. An acting manager had been recruited to manage the home in her absence, and the Service Manager explained that they would be given a full management induction into the home and also had previous management experience. The home also has 2 deputy managers, both of whom were present at the time of inspection and were able to demonstrate good knowledge of the service and of the people who use it. It was clear that the temporary absence of the registered manager had been planned for to ensure continuity of management of the service. Care Homes for Adults (18-65 years) Page 22 of 26 Evidence: SFL have a system in place for quality assurance. This includes a monthly health and safety audit that covers all safety aspects of the home. Any shortfalls identified are then reported to the relevant department for remedial work to be carried out. They also have key performance indicator assessments that audit various areas of the home to include training, complaints, referrals and vacancies. This also records any action to be taken taken to address any shortfalls identified. Regulation 26 unannounced visits are carried out on behalf of the registered provider and reports from these visits are available. One month had been missed, and we discussed ensuring that these visits were carried out monthly in the future. Weekly staff meetings take place and minutes are recorded. There are monthly management meetings with the CTPLD team. The Service Manager has identified the need to carry out surveys for those using the service in order to gain information to further improve the service and tailor it to the needs of those people who use it. We sampled the servicing and maintenance records and those viewed were up to date. The Service Manager has advised that the 5 year electrical circuit testing that was due in January 2010 was postponed due to bad weather, and has been re-booked for February 2010. Policies and procedures are in place and were last reviewed in October 2009. Risk assessments were in place for equipment and safe working practices. Staff receive training in health and safety topics as part of the induction programme and receive updates at the required intervals. Fire drills are carried out for day and night staff and records are maintained. There is also a fire ability document for each person who uses the service, to identify their needs and abilities in case of fire. Daily health and safety checks to include fridge and freezer temperatures, faults, window locks, door locks and water temperatures in all areas. There were no health and safety issues identified during the tour of the home. Care Homes for Adults (18-65 years) Page 23 of 26 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 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 Risk assessments should be reviewed regularly even where it is felt that the risk has not changed, in order to evidence that the risk assessment has been revisited and is being kept under review. Where the dose of a medication changes, the original entry on the MAR should be crossed through and a new entry made to clearly reflect the new dose. That any medications held in the home be dated when opened so that the recommended shelf life for a particular medication once opened is not exceeded. That the dining and sitting rooms be redecorated. 2 20 3 20 4 24 Care Homes for Adults (18-65 years) Page 25 of 26 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 26 of 26 - 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!