Care Home: 25 Barossa Road

What the care home does well The service provides a friendly, relaxed, homely and welcoming atmosphere.During this visit good relationships were observed between people and staff. People were seen participating in household tasks including, washing up and laying tables, helping themselves to drinks and snacks and choosing their preferred meal. Detailed and comprehensive care plans were in place, which were person centred in approach and implemented in consultation with people living in the service. Clear information was recorded about peoples likes and dislikes, their individual preferences and choices. A person living in the service told us that they attend meetings in the home. People are supported to attend a wide range of recreational and social activities. During this visit some people told us about the activities that they participate in, including, attending day services, further education, work experience visiting the theatre, going shopping , going bowling and some people were discussing their forthcoming shopping trip with a member of staff . A person living in the service said, " We go out for lunches, we go to shows at the theatre" Another person said, "I am going bowling and we are going to buy a take way meal and "we go out for a game of pool at the pub and I am very happy". The home has implemented an accessible complaints procedure, which contain pictures and photographs . People living in the service said that they knew who could they approach if they had a concern and that staff listen to their views. One person commented, ""The staff listen and let you talk to them". People are supported by a staff team that have a good knowledge of people`s needs, they are well trained to meet their needs. The home has implemented good quality assurance systems ensuring that the home is run in the best interest of people living there. What has improved since the last inspection? Since the last key inspection the home has reviewed their contracts. The registered manager has attended the local authority safeguarding vulnerable adults from abuse training. The kitchen has been refurbished What the care home could do better: One good practice reccomendation was made as aesult of this inspection Key inspection report Care homes for adults (18-65 years) Name: Address: 25 Barossa Road 25 Barossa Road Camberley Surrey GU15 4JE     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Lisa Johnson     Date: 0 3 0 6 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 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: 25 Barossa Road 25 Barossa Road Camberley Surrey GU15 4JE 0127666047 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ann.Kemp@mencap.org.uk www.mencap.org.uk Royal Mencap Society care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 8. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home 25 Barossa Road is a large detached property located in a residential area of Camberley, close to the shops, recreational facilities and other amenities of the town centre. The home is owned and managed by the Royal MENCAP Society and provides accommodation and care to up to eight people who have a learning disability. Communal areas consist of a good size lounge and a large kitchen/dining area. All bedrooms are single occupancy and have a hand washbasin fitted. No bedrooms have en-suite facilities. The accommodation is arranged over two floors with the first Care Homes for Adults (18-65 years) Page 4 of 27 Over 65 0 8 Brief description of the care home floor being reached by staircase. There is no passenger lift or chairlift fitted. There is a garden to the rear of the property that is accessible to the service users and off road parking for two cars to the front of the building. The home does not have its own vehicle, however access to public transport is located close by. The fees charged in this service range from £328 to £542, which does not include the accommodation provided. Care Homes for Adults (18-65 years) Page 5 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: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This visit was part of a key inspection, which took place over six hours commencing at 11.50am and finished at 6.45 pm This inspection was carried out by Mrs. L Johnson. The service was represented by Ms. A Kemp registered manager. The last key inspection was carried out 19th July 2007 and we also carried out an annual service review in July 2008. Information was provided to us by the registered manager prior to this visit in the Annual Quality Assurance Assessment (AQQA). This is a self assessment that focuses on how well outcomes are being met for people living in the service. During this visit we had the opportunity to meet with five people who live in the service and a member of staff. We received feedback surveys from seven people who live in the service, three staff surveys and two health and social care care professionals. Care Homes for Adults (18-65 years) Page 6 of 27 Comments that were received are reflected in this report. During this visit we looked around the home and three people living there invited us to view their bedrooms. We sampled three peoples support plans, risk assessments, medication administration records, menus, staff personnel and training records, quality assurance systems and policies and procedures. Care Homes for Adults (18-65 years) Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our 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. People are provided with information,which they need to know to make an informed choice about the suitability of the home as a place to live. Peoples needs are assessed prior to admission to the home. Evidence: The service has a statement of purpose and service user guide in place known as People we support guide, which has been made accessible to people with the inclusion of pictures and photographs to make this information more interesting. The home currently supports both younger and older people and it was recommended that the manager includes more detail in the statement of purpose as to how the differing needs of people are met. Since our previous visit there have been no new people admitted into the home. The service has an admission policy, which includes an assessment process that involves gathering information about the person including, an assessment from the care manager, health care professionals and other important people to them to ensure that the service can meet the persons needs. Care Homes for Adults (18-65 years) Page 10 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a plan of care that the person has been involved in making. Peoples needs and goals are met and they are able make decisions about their life. People are able to take risks as part of an independent lifestyle. Evidence: Each person has person centred support plan in place. During this visit we sampled three peoples support plans. These were clear, detailed and comprehensive and covered peoples health, personal, emotional, communication, social, cultural and spiritual needs. Care plans have been designed to make them accessible to people with the use of pictures and photographs. Information seen demonstrated that people are consulted about their care plan and their agreement has been obtained. Where people have chosen to maintain a copy of their care plan this had been documented. Monthly review meetings take place with people and their key worker using an accessible format and the outcomes are recorded to include peoples new goals. Daily significant events are recorded and read and sign systems are in place to ensure that Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: staff are aware of the content of each persons plan. Four members of staff confirmed that they are always given up to date information, about the needs of people they support and the means of sharing information with the manager and other carers works well. The home proactively supports people in making decisions and choices about their daily lives and listen to their views. Information supplied in the AQAA states that the manager monitors the outcomes of monthly person centred planning meetings to ensure that peoples requests are met. A person living in the service had requested that they wish to attend a different adult education centre, which was pursued. Regular home meetings are held,which are recorded where matters including menus, shopping and choosing outings and holidays are discussed. People have been provided with the opportunity to take part in staff selection. People are supported to maintain their independence and risk assessments that have been implemented support this. Risk assessments have been enhanced with photographs to make these easier for people to understand when discussing them. Risk assessments sampled included bathing, cooking, managing finances, accessing the community and using transport. Risk assessments had been reviewed and were up to date. Care Homes for Adults (18-65 years) Page 12 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples preferences, social, cultural, diverse ,religious and recreational interests and needs are met. People maintain contact with their family , friends , representatives and the local community. People are supported to exercise choice over their lives and are provided with varied and well balanced meals. Evidence: Each person has an individual programme of activities, which meets with their needs and preference and information seen demonstrated that people participate in a wide range of appropriate work, educational, recreational and social activities. During this visit one person told us that they work in a cafe and that they go the gym and attend college. Information supplied in the AQAA states that six out of seven people living in the service attend day services outside of the home and four people have now passed Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: retirement age. One person decided that they longer wish to attend their day services and two people told us that they attend an older persons day service, which they said that they very much enjoyed, where they take part in activities such as cooking and exercise classes. People access community facilities such as visiting shops, cinema, cafes, pubs social clubs, swimming, bowling, theatre trips and some people use local transport. During this visit a discussion took place between a member of staff and people about their shopping trip to Farnborough and what they wished to purchase. People are able to choose their preferred holidays and some people told us that they enjoyed their holiday to Hayling Island this year. One person told us that they attend church on Sunday ,which meets their spiritual needs. The home maintains detailed records of activities that people have taken part in. People maintain links with their families and friends and people spoken with told us about their families whom they visit. One persons care plan identified that they like to write letters and make phone calls. Information supplied in the AQAA states that there is a families charter, which clearly outlines the ways in which staff works with families. People living in the service are fully involved in household activities. A pictorial task rota was seen on the kitchen notice board detailing who is responsible for carrying out specific activities in the home. At the time of this visit people were observed washing up, one person was laying the table and another person was being supported to hang their washing out in the garden. Each person has a home day where they also participate in household activities including cooking. The service was relaxed and provided a homely, inclusive, friendly atmosphere and people were observed to be making themselves drinks and snacks on return from their day activities. Good relationships were observed between people an staff who were seen to be caring respectful and attentive. People are provided with keys for their bedrooms if they wish to use these and one person said that they have a key for the front door. The home has a cat called Molly whom people help take care of . The home has menus in place , which were based on peoples preferences. Each day of the week people can choose their favourite meal. People assist in preparing and cooking their meal usually on their home day. Menus were observed to be varied and well balanced and staff are aware of peoples nutritional needs. At the time of this visit the home was having a take away meal and staff were observed to asked everybody what their preferred choice was. Care Homes for Adults (18-65 years) Page 14 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. Peoples health and personal care needs are met and peoples preferences for support are respected. The home supports people with their medication in a safe way. Evidence: Peoples personal and health needs are identified a part of their person centred support plan and health action plans are implemented. Peoples likes and dislikes, preferred routines were clearly recorded and their preferred ways of support and gender of staff were also recorded. Care plans provided detailed and clear information and guidance to staff how peoples support is to be provided. Information seen demonstrated that there is a person centred approach to care and support. One persons care plan stated that they prefer their bath in the evening and the bathroom, which they like to use and their favourite bath additive ensuring that this is an enjoyable experience for them. Another persons plan identified that they prefer to take a shower. Information seen during this visit demonstrated that people are supported to access a range of health care professionals including, general practitioner, dentist, chiropody, Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: opticians and two people are supported for the management of their diabetes by a diabetic nurse and hospital specialist. During this visit a person recieved a visit from a health care professional. Detailed records were maintained of all health care consultations that people attend. Two health and social care professionals surveyed said, Peoples health needs are are properly monitored, reviewed and met by the service and The service always seeks advice and act it to meet peoples health and social needs. The homes medication practices were examined. Medication is dispensed using the monitored dose system (MDS). Systems are in place for the receipt and disposal of medication. As the home has not been audited for sometime by their pharmacist the manager was advised to follow this up with them as good practice. A list is maintained of staff trained and authorised to administer medication. Staff receive medication training and annual medication observation assessments are conducted. Peoples medication administration record contained a photograph of the person for identification and medication administration records sampled had all been signed. Medication profiles were in place and any allergies are identified. One person is supported in self administering their insulin and risk assessments and guidelines were in place. The service has a homely remedies protocol in place. Care Homes for Adults (18-65 years) Page 16 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. If people have concerns they know how to complain and they are safeguarded from abuse Evidence: The service has a complaints procedure in place, which is also formulated in a pictorial chart, which was seen on display in the hallway. The procedure explains to people how and who they can raise concerns to. Complaint forms are also available. Records are maintained of any informal complaints received,which we viewed during this visit and information seen demonstrated what action had been taken in response to peoples concerns. During peoples monthly review meetings complaints and concerns are discussed as part of the agenda. People surveyed and spoken with during this visit told us they knew who they would speak to if they had any concerns and said that staff listen to what they say. Comments received included, The staff are very kind;The staff are nice and they listen and let you talk to them and Everthing is good. Since our previous visit no complaints have brought to the attention of the Commission. Safeguarding vulnerable adults from abuse and whistle blowing procedures are in place. The home has also obtained the most recent local authority multi agency procedures. Staff training records sampled demonstrated that they have received safeguarding training and prior to this visit three members of staff including the Care Homes for Adults (18-65 years) Page 17 of 27 Evidence: manager had attended Surrey safeguarding vulnerable adults from abuse training.A member of staff spoken with was clear about their responsibilities should they witness or be made aware of any incident where the safety of people is compromised. Care Homes for Adults (18-65 years) Page 18 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. People live in a home that is in the main safe, comfortable, homely and clean. Evidence: People live in homely environment that is decorated and furnished to a good standard. There is a comfortable sitting room and large/kitchen diner, which has been refurbished since out previous visit. People are consulted about their preferred decor and the bathrooms have been painted in colours meeting with peoples preference. An accessible bath is also available. There is a garden and patio to the rear of the property and garden furniture was available. The garden would benefit from some further tidying up as it was overgrown in some areas. We were informed that a member of staff and some people living in the home are now involved in undertaking some gardening tasks. Information supplied in the AQAA states that since our previous visit three bedrooms have been redecorated. During this visit three people invited us to view their bedrooms, which were comfortable, well decorated, furnished, personlised and reflected peoples gender. While looking around the home it was observed that there were window restricters Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: missing on both floors. The registered manager told us that this matter has been addressed with the housing association who are responsible for the homes maintenance and they are waiting for new windows to be fitted throughout, although the date for this work to be carried out has not yet been identified . The registered manager has ensured that risk assessments have been completed in respect of this matter, which were in place at the time of this visit. During this visit it was observed that one window on the ground floor opened right out, which poses a security risk. Therefore the registered person should ensure that this matter is pursued with the housing association ensuring the welfare and safety of people living in the service. At the time of this visit the home was observed to be cleaned to a good standard and was hygienic. Separate laundry facilities are available, infection control procedures are in place and staff receive training in food hygiene and infection control. Since our previous visit the home has received a visit from environmental health department. This report was viewed, which recorded a satisfactory outcome. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are supported by staff that are competent and trained to meet their needs and they are protected by the homes recruitment policies and practices. Evidence: The home currently employs five members of staff that work flexibly to meet the needs and lifestyles of people. Staffing numbers can vary from one to two members of staff on duty during the day and people are supported by a sleep in member of staff at night time. Currently two members of staff hold national vocational qualifications and another member of staff is in the process of completing the qualification. The manager told us that they are intending to register the two most recently appointed members of staff on to the programme. New staff receive induction and foundation following Skills for Care core induction standards. During this visit we viewed the induction records for one member of staff which were detailed and comprehensive. Staff are also provided with the General Social Care Code of conduct(GSCC)ensuring that they are aware of their roles and responsibilities working in a social care setting. People using the service are protected by robust recruitment practices. During this Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: visit we sampled three members of staff personal files, which contained the required information including a completed application form, two written references and enhanced criminal records bureau check (CRB). Some people living in the service are involved in the staff recruitment process and information was shown to us to verify this, which included questions that people have asked applicants about matters that are important to them. The manager maintains a staff training schedule, which details all of the training that staff have received. Staff training schedules sampled demonstrated that their statutory training is up to date. Staff receive specialist training to meet the needs of people they are supporting including person centred planning , risk management , diabetes, epilepsy and one member of staff had attended introductory, dementia awareness training. Three members of staff surveyed and spoken with during this visit confirmed that they receive appropriate training to meet peoples needs. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run in the best interests of people living there and their wellbeing, health and safety is in the main protected. Evidence: The home is run well and managed by an experienced registered manager who has long experience of working with people with learning disabilities. The manager informed us they are near to completing their National Vocational Qualification (level 4) and registered managers award (RMA). During this visit the manager was observed to have an open, accessible and inclusive approach with both people living in the service and staff. A person using the service told us, The manager is very good. Members of staff surveyed said that there is good team work, effective communication, they feel well supported by the management structure and that the home is happy place to work. The home is run in the best interests of people living there and good quality assurance systems are in place. The registered provider conducts monthly quality monitoring Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: visits , which are now recorded electronically, which we were able to view during this visit. These reports were detailed, comprehensive, and included action plans. Information supplied in the AQAA states that the organisation (Mencap) have introduced a continuous improvement framework that sets out how services promote and assure quality. During this visit we viewed some of the documents which addresses areas including, person centred planning, compliance, environment, systems and feedback from people using services. Action plans are continuously reviewed.The service is also reviewed annually. A member of staff surveyed said, Through regular team meetings we try to find ways,which can contribute to our continuous improvement plan, which ensures we constantly strive to improve our working practices Systems are in place ensuring peoples safety including regular health and safety audits. Water temperature monitoring takes place and regular servicing and maintenance of equipment takes place, which was confirmed by records sampled at the time of this visit. We were informed that the fire authority has recently visited the home and actions have been taken to meet their requirements and recommendations. Staff receive appropriate training including health and safety, moving and handling and first aid. One matter was identified, which must be attended to in respect of the unrestricted windows (See standard 24 ). 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 1 1 It is recommended that the statement of purpose includes in detail how the differing age needs of people living in the service are met. 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!