Care Home: 22 Millcroft

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What the care home does well People living in the home are supported by staff who know them well and who are strong advocates for them to ensure their individual rights are protected. There are good staffing levels to ensure the needs of people using the service can be met and staff involve relatives and professionals well to ensure the best interest of those living in the home are promoted. Relative feed back about the home was very good and one told us `The service my sister receives has always been excellent, they are like a family to her`. What has improved since the last inspection? The manager had worked hard to improve the service with good progress made to implement the requirements and recommendations we made previously. Clear information was now available about the home`s transport to enable people to know about the costs of using this. Action had been taken to provide more staff training to enable them to do their jobs well and ensure they know how to safeguard people living in the harm from potential harm. Information about people living in the home had been further developed to enable staff know how to support them properly. What the care home could do better: The home`s statement of purpose must be updated to include the correct married name of the Registered Manager to ensure people thinking about the service have up to date information about the home. Risk assessments for people using the service must be regularly reviewed and followed up to ensure they are protected from potential harm. Medication administered to people using the service must be given as prescribed and accurate records of these are kept and all errors concerning them reported to the Care Quality Commission. This to ensure people using the service are safeguarded from potential harm. The maintenance programme for the home must be developed and satisfactory arrangements for refurbishments carried out to ensure a more comfortable and pleasant environment is provided. Significant events must be reported to the Care Quality Commission to ensure the rights and best interests of people using the service are safeguarded. A monthly report of visits to the home by a senior manager must be written and submitted the Care Quality Commission to ensure a competent and accountable management supports people using the service. People using the service should be provided with further opportunities to ensure individual social, recreational and personal development. Pictorial information should be developed to enable people using the service to be further supported to make positive choices. Health action plans should be reviewed and kept up to date. A minimum of 50% of the care staff should obtain an NVQ at level 2 or above and a formal training and development matrix be developed to help the manager know when staff training needs updating. The Quality Assurance systems for the home should be developed to ensure the home can monitor its performance in meeting its aims and objectives. Key inspection report Care homes for adults (18-65 years) Name: Address: 22 Millcroft Warley Road Scunthorpe North Lincolnshire DN16 1QL     The quality rating for this care home is:   one star adequate 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: Rob Padwick     Date: 2 3 0 9 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 31 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 31 Information about the care home Name of care home: Address: 22 Millcroft Warley Road Scunthorpe North Lincolnshire DN16 1QL 01724282720 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: kirsty.neal@new-era.org.uk www.dimensions-uk.org Dimensions (UK) Ltd care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Date of last inspection Brief description of the care home 22 Millcroft is a care home providing personal care and accommodation for six adults aged 18-65 years with learning disabilities. Three of these places are for service users who also may have a physical disability. It is owned by Dimensions (UK) Ltd and is situated close to two other homes owned by the same Company. The home is located in a residential area close to the centre of Scunthorpe. It is close to local shops, amenities and public transport. The home has its own transport. The home is a purpose built bungalow. All bedrooms are single and have wash hand basins fitted. Bedrooms are decorated and furnished to meet individual service user requirements and preferences. Communal areas of the home are decorated and furnished in a domestic style. Aids and adaptations have been provided as required to meet service users needs. All the service users living in the home are female. Information on fees can be obtained from the manager of the home. At the time of the Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 0 6 3 Brief description of the care home site visit the current fees were £894.74 per week. Some of this is met through the income support claimed by the service users. All people that currently live in the home are funded through their local authority and any third party payments towards the fees have been agreed through the correct arrangements. Information on the service is made available to prospective and current people that live at the home through the services statement of purpose, service user guide and previous inspection reports. Copies of these documents can be obtained from the manager and several of them are available in the entrance to the home. Care Homes for Adults (18-65 years) Page 5 of 31 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: one star adequate 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 inspection report is based on information received by The Care Quality Commission since the last time we visited the service on 20th November 2007 and includes information gathered during a site visit to the home. As part of the inspection process, we send out a self assessment document that the Registered Person must complete and return to us. This helps us know how well the home is meeting regulations and National Minimum Standards and what has been done to improve it and what still needs to be done. The group of people using the service have a variety of complex needs and communication difficulties, which means none could tell us directly about their care, however we observed interactions between them and the staff. Other information used included feedback from relatives Professional staff who know people using the service well, together with official notifications sent to us by the home. This information helps us to reach judgments about the service provided. The site visit took place on 23rd September 2009 and lasted for 6 hours. The Care Homes for Adults (18-65 years) Page 6 of 31 provider was not told in advance when it would take place. The manager was available throughout the period of our site visit and as well as speaking to her, we spoke to staff who were on duty and observed people using the service. We looked round the building, including the bedrooms and shared areas of the home and we inspected the records of peoples care, staff files, health and safety documents and other records kept by the service. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: The homes statement of purpose must be updated to include the correct married name of the Registered Manager to ensure people thinking about the service have up to date information about the home. Risk assessments for people using the service must be regularly reviewed and followed up to ensure they are protected from potential harm. Medication administered to people using the service must be given as prescribed and accurate records of these are kept and all errors concerning them reported to the Care Quality Commission. This to ensure people using the service are safeguarded from potential harm. The maintenance programme for the home must be developed and satisfactory arrangements for refurbishments carried out to ensure a more comfortable and pleasant environment is provided. Significant events must be reported to the Care Quality Commission to ensure the rights and best interests of people using the service are safeguarded. A monthly report of visits to the home by a senior manager must be written and submitted the Care Quality Commission to ensure a competent and accountable management supports people using the service. People using the service should be provided with further opportunities to ensure individual social, recreational and personal development. Pictorial information should be developed to enable people using the service to be further supported to make positive choices. Health action plans should be reviewed and kept up to date. A minimum of 50 of the care staff should obtain an NVQ at level 2 or above and a formal training and development matrix be developed to help the manager know when Care Homes for Adults (18-65 years) Page 8 of 31 staff training needs updating. The Quality Assurance systems for the home should be developed to ensure the home can monitor its performance in meeting its aims and objectives. 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 9 of 31 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 10 of 31 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. The needs of people using the service are care fully considered as part of their admission to the home and information is available to help people thinking about using the service to make an informed decision about it. Evidence: Pictorial information was available in a statement of purpose and service users guide to help people thinking about using the service to make an informed decision about using it. Since the last time we visited, financial information had been included within the service users guide to give further details about the costs of using the transport in the scheme as previously required. There was evidence the Statement of Purpose still needs further updating to include the managers married name and details about the Care Quality Commission and a requirement is made about this. The group of people living in the home have a variety of complex needs and communication difficulties, which means they were unable to tell us about the home; however we observed positive interactions between them and the staff that indicated they felt safe and that their needs were appropriately met. Relative feedback was very Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: positive about the service and told us that staff always treat people living in the home very well. The file of an individual who had moved in since our last visit indicated their needs had been carefully considered as part of their admission to the home. There was evidence of assessments carried out by the Local Authority, together with meetings and planned visits to the home to ensure the service was able to meet their needs appropriately. Care Homes for Adults (18-65 years) Page 12 of 31 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. The rights of people living in the home are supported by staff who are strong advocates for them and who involve them in decisions to ensure their needs and wishes are properly met. Evidence: The files of people living in the home indicated the service adopts a very person centred and there was evidence support plans had been developed for people using the service to ensure their needs are met in a way that had been fully discussed and agreed with people that know them well. The case files included daily recordings to show staff were delivering the required support; together with monthly support plan evaluations to make sure they remain up to date. The case files inspected contained assessments about the management of risks to people living in the home and staff were observed to be knowledgeable about them and have a good understanding of them. One of the risk assessments however identified need to monitor an individuals weight on a regular basis, however despite this, follow up actions had only been recorded once and a requirement is made about this. Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: As indicated previously, the group of people using the service have a variety of complex needs and communication difficulties which meant it was hard to for them to tell us about their lives. Nursing health professionals however, told us staff were very strong advocates for people using the service and we saw strong evidence of this with good consultation and multi disciplinary involvement to ensure their best interests are properly met. An Independent Advocate had been appropriately involved to assist with important decisions about various health interventions and assessments carried out under the Mental Capacity Act 2005 in relation to this. A Social Work specialist told us staff Provide individualised care whilst respecting and responding to the persons needs and taking advice from other professionals, whilst feedback from relatives was very positive and one said the service my sister receives has always been excellent. Care Homes for Adults (18-65 years) Page 14 of 31 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. Whilst people living in the home are encouraged and supported to take part in opportunities for personal and social development, further development and use of visual aids would enable more active choices about these. Evidence: Owing to the complex nature of needs experienced by people living in the home they are unable to maintain employment but we observed they are supported to take part in opportunities for social interaction and activities. There was some evidence these should be further developed and the manager told us they were aware of this. A recommendation is made about this. On the day of our visit two people living in the home were supported to go shopping and have lunch out, whilst case files and records showed one was supported to attend a local church group and coffee morning and another to join in a social group for older people. One of the bedrooms in the home has been converted into a sensory room and we were told this was used to support Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: personal activities such as hand and foot massages provided by staff. The home has access to two mini buses which are shared with two sister homes locally and records in the service contained evidence of various trips out and visits to places of interest. Following a requirement the last time we visited explicit information was now available about funding of these. People living in the home are encouraged and supported to maintain contact with families and we received positive comments from relatives and evidence of good partnership work with them. Case files contained information about the likes and dislikes of people living in the home and we observed staff supporting them well with their meals which were appropriately presented. We were told pictorial menu choice boards had been previously used to help identify positive choices about meals and a recommendation is made about this. Assessments about the nutritional needs of people living in the home had been carried out, however there was evidence action concerning these had not always been followed up fully owing to a lack of appropriate equipment in the home. The manager told us she was in the process of exploring options about this with the local Health Trust, however a requirement is made about this. Care Homes for Adults (18-65 years) Page 16 of 31 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. The health and personal care needs of people living in the home are met in a person centred way by staff who are strong advocates for them, however improved recording about medication would ensure they are safeguarded better from potential harm. Evidence: As indicated elsewhere in this report, most of the people using the service are a long standing group and have a variety of complex health and personal care needs, together with difficulties in communicating these verbally. Support plans had been developed from the assessments of people living in the home which identified how staff should assist them and indicated significant levels of support were sometimes required. Regular recording and monitoring of needs were documented in case files inspected, together with close liaison with Community professionals to ensure they continue to be appropriately met. Some case files included Health Action plans, however others needed to be further developed and recommendation is made about this. A Learning Disability nurse said she had No worries regarding the health needs of people using the service and that staff were strong advocates in respect of their health entitlements. We observed staff interacting with people living in the home in a positive manner and it was evident they had a good understanding of them and knew Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: them very well. A relative told us xxx has more or less had the same carers for the whole time she has been at Millcroft .. they are like a family to her . Policies and procedures were available to ensure staff know how to administer medicines safely and we saw evidence of appropriate training that covered this element of practice. Whilst we saw evidence of some medication errors which had not been correctly reported to us, there was evidence the manager had taken action about these and that staff were now checking these each time they came on shift. A random check of medication records however indicated a PRN medication was being given on a regular basis when an up to date prescription for this had not yet been received. A requirement is made about this as this places people using the service at potential risk of harm. Care Homes for Adults (18-65 years) Page 18 of 31 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 concerns and complaints of people using the service are taken seriously and staff training provided to ensure they know how to safeguard them from potential harm. Evidence: The home has policies and procedures to ensure the complaints of people using the service are taken seriously and that action is taken to follow up any concerns. No complaints had been received by us since the last time we visited the service and the self assessment indicated none had been made to the home. As previously indicated none of the people living in the home have the capacity to fully understand the process for making a complaint; however we received positive feedback from professionals who are regularly involved who told us they were confident any concerns would be dealt with appropriately. We saw evidence the manager had taken appropriate action to follow up a previous requirement to ensure people using the service are safeguarded from potential harm and that further training on this had been had been arranged. Regular checks were being carried out of medication given to people living in the home and records of monies held by the service on their behalf were accurate and appropriately kept. Care Homes for Adults (18-65 years) Page 19 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst the home was comfortable and was being generally appropriately maintained, a further upgrade and redecoration of the building would ensure a more pleasant environment is provided. Evidence: On the day of our visit the home was clean, tidy and free from offensive odours and new flooring had been laid to the dinning room to make it easier to clean. The lounge area was comfortably furnished and of a domestic nature, however there was evidence the building was in need of a general upgrade and refurbishment, as some walls needed repainting and the carpets in the bedroom corridor area were in need of replacing. The manager told us she was aware of this situation, but indicated decisions about this were with senior management and a requirement is made about this. On the day of our visit an engineer was visiting to discuss arrangements for installing a new assisted bath, as the one currently in use was in need of replacement. Bedrooms inspected were clean and comfortably decorated and reflected the personal preferences and interests of people living in the home. The garden area had been further developed since our last visit and pleasantly landscaped with flowers and shrubs that made it a peaceful space to use. The self assessment for the service told us a bedroom had had been equipped as a sensory room. There was evidence of staff training about health and safety issues and safety checks were being carried out to Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: ensure the building was safe and properly maintained. Staff told us they had aprons and gloves to minimise spread of infection and the manager told us she was planning to provide an information session about infection control. Care Homes for Adults (18-65 years) Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are supported by a committed and caring staff team who have been generally well trained to ensure they can do their jobs. Evidence: We observed staffing levels to be appropriate for meeting the needs of the current group of people using the service and the manager told us additional funding had been obtained for them due changes in their assessed needs. At the time of our visit there were three support staff working with the four people who live in the home and interactions between them were observed to be friendly and approachable. Staff indicated they were committed to doing their jobs well and that they enjoyed working in the home. Staff told us they were provided with regular training and professional supervision to help them to do their work and staff files inspected contained confirmation of this, with identified training and development opportunities and a variety of certificates from various appropriate courses. Information in the self assessment told us about progress in meeting a previous recommendation and that 45 of the staff team had now obtained an NVQ2 in care and that another 27 of them are currently working toward this level of qualification. The manager told us new staff are also enrolled on a specialist Learning Disability course, but that some of the long standing staff team Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: have expressed a reluctance to do this. The manager showed us information she had compiled to tell when staff training up dates are required, however this was rather basic and it is recommended a formal training and development matrix is developed. Whilst there was evidence of appropriate foundation and mandatory training to enable staff to develop their skills, it is recommended and with particular consideration of the complex needs of people living in the home, that this is extended to include additional elements related to communication, Deprivation of Liberty and the Mental Capacity Act 2005. This will enable staff to develop their skills further in supporting people living in the home. Policies and procedures were in place to ensure staff are properly recruited and safe to work with people living in the home. The company that runs the home has a policy of not starting staff before a full Criminal Records Bureau check is received for them. Although no actual documentation about these were available in the service as they are kept in the company Headquarters and checked by us nationally, we were shown a computer print out that confirmed appropriate checks had been carried out by the company Personnel department. Care Homes for Adults (18-65 years) Page 23 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst management systems are in place to support the running of the service, further development of these would ensure the welfare and best interests of the people living in the home are better promoted. Evidence: The registered manager has worked in the home for seven years and has completed five units of her Registered Managers Award. She told us due to continued problems with the company providing training she had not yet been able to complete it as previously recommended and had therefore registered with another training company. The manager has BTEC National Diploma-Caring Services (Social Care) and takes a hands on and open style of management. There was evidence she was strongly committed to meeting the needs of people using the service and relative feedback was very positive about the home. Staff told us the manager was very supportive and listened to them well and that regular meetings were held to ensure good communication and a positive team approach. We made a requirement the last time we visited that quality assurance systems are Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: developed for home and whilst we saw evidence of surveys subsequently developed, the manager acknowledged these could be further improved to enable further involvement with relatives and people who know the service. There was evidence of audits of the service to enable it to monitor its effectiveness, however some of were somewhat basic and needed further development and formalised. The self assessment gave a reasonable picture of the current situation within the service, however there were areas where more supporting evidence would have been useful to illustrate what had been done over the past year and some information about how it was planning to improve was only briefly explained. Required monthly visits from a senior manager for the company had not taken place since December 08 and a requirement is made about this to ensure the manager is effectively supported and the welfare of people using the service properly promoted and protected. Regular checks were being carried out of the building and equipment to ensure the health and safety of people using the service was properly safeguarded, however we saw evidence some incidents had not been reported to us as required and a requirement is made about this. Care Homes for Adults (18-65 years) Page 25 of 31 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 26 of 31 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 1 1 4 The Registered Person must ensure the homes statement of purpose is updated to include the correct married name of the Registered Manager. This is to ensure people thinking about the service have up to date information to help them make an informed decision about using the home. 31/12/2009 2 9 13 The Registered Person must ensure risk assessments are regularly reviewed and follow up actions are recorded. This is to ensure people using the service are protected from potential harm. 30/11/2010 Care Homes for Adults (18-65 years) Page 27 of 31 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 3 17 12 The Registered Person must ensure that appropriate action is taken to ensure people using the service can be regularly weighed. This is to ensure the nutritional needs of people living in the home can be monitored. 26/02/2010 4 20 13 The Registered Person must 30/11/2009 ensure medication is administered to people using the service as prescribed and that accurate records of these are kept and that all errors concerning this are reported to the Care Quality Commission. This to ensure people using the service are safeguarded from potential harm. 5 24 23 The Registered Person must 31/12/2009 develop the maintenance programme for the home and make satisfactory arrangements for refurbishments to be carried out. This to ensure people using the service are provided with a more comfortable and pleasant environment in which to live Care Homes for Adults (18-65 years) Page 28 of 31 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 6 41 37 The Registered Person must 11/11/2009 ensure significant events are reported to the Commission. This is to ensure the rights and best interests of people using the service are safeguarded. 7 43 26 The Registered Person must write a monthly report following visits to the home and submit this to the Care Quality Commission. This is to ensure people using the service benefit from a competent and accountable management of the home. 12/12/2009 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 12 The Registered Person should continue to ensure people using the service are provided with appropriate opportunities for to ensure individual social, recreational and personal development. The Registered Person should develop the use of pictorial information boards in the home to enable people using the service to be further supported to make positive choices. The Registered Person should ensure health action plans are reviewed and kept up to date. The Registered Person should continue to ensure a minimum of 50 of the care staff have achieved NVQ at Page 29 of 31 2 17 3 4 19 32 Care Homes for Adults (18-65 years) 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 level 2 or above. This is to ensure they have the right knowledge and skills to care for the people that live at the home. 5 35 The Registered Person should ensure staff receive training about specialist communication needs and the Deprision of Liberty and Mental Capacity Act 2005. The Registered Person should ensure that a formal training and development matrix is available to help the manager know when staff training needs updating. The Registered Person should develop the Quality Assurance systems for the home in order to ensure it can monitor its performance in meeting its aims and objectives. 6 35 7 39 Care Homes for Adults (18-65 years) Page 30 of 31 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. 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