Care Home: 4 Beech Close

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What the care home does well Staff we spoke with were happy to be working at 4 Beech Close. Their comments included: "I like working with all the staff. We all really work as a team, which is very good"; "There have been big changes in all the guys who live here - big improvements"; "I genuinely enjoy working here - no 2 days are the same - we`ve got a good team"; "Management is supportive"; and "Training is spot on". We spoke to a relative of one of the people who lives here. She said he settled in well and is very happy. Good information about the home is available, written in a way which most people using the service could understand, and thorough assessments of people`s needs have been carried out. Care plans are written in a person-centred way and give staff good guidance on how each person wants to be supported. The staff make sure people see healthcare professionals if they need to, and they look after people`s medicines well. People know that staff will listen to any complaints they might have, and staff told us they know what to do if they think someone is suffering from abuse. Staff are recruited well and receive regular supervision. Four permanent staff have been awarded a National Vocational Qualification (NVQ) in care, and staff have been able to go on a range of training courses. Records are kept as required, tests of the fire alarm and emergency lighting systems are done regularly, and people`s views on the quality of the service being offered are sought. What has improved since the last inspection? The new manager has worked hard, along with the staff team, and the home has moved forward. The requirements we made last time have been met, so all staff have had training in relevant topics; a manager has been appointed (and registered with CQC); and health and safety issues have been dealt with. The recommendations we made have also been addressed. What the care home could do better: We have confidence, from our discussions, and from her responses in the AQAA that the manager is aware of areas where the service should continue to improve. We have not made any requirements this time, however, areas where the service could do better include: - produce a statement of terms and conditions (contract) which service users and/or their representatives sign to show that they are clear about what they can expect from the service; - continue to improve the range and amount of activities, and the opportunities to develop independence skills, offered to the people who live here; - access NVQ (or equivalent) training for staff so that the whole staff team is qualified; and- make sure the building, and the furnishings and equipment, continue to meet people`s changing needs. Key inspection report Care homes for adults (18-65 years) Name: Address: 4 Beech Close 4 Beech Close Dunstable LU6 3SD     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: Nicky Hone     Date: 1 4 0 4 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 28 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: 4 Beech Close 4 Beech Close Dunstable LU6 3SD 01582434336 01582434337 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Affinity Trust Name of registered manager (if applicable) Regina Ncube Type of registration: Number of places registered: care home 4 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: 4 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 care needs on admission to the home are within the following category: Learning disability Code LD Date of last inspection Brief description of the care home 4 Beech Close is a home for up to 4 adults with learning disabilities. The home was registered in January 2009 and at the time of this inspection there were 3 people living here. The home is managed by Affinity Trust who provide the care and support. MacIntyre Housing Association owns the property and is responsible for its maintenance and upkeep. 4 Beech Close is a bungalow, situated a few minutes walk from the A5 and about 1 mile from Dunstable town centre. There are some local shops, and a good bus service close by. It shares a site with 3 other registered care homes and a resource centre. The bungalow has 4 single bedrooms, each with its own sitting Care Homes for Adults (18-65 years) Page 4 of 28 Over 65 0 4 Brief description of the care home room across the hallway. There are 4 bath/shower rooms, a kitchen, laundry room, dining room and 2 large lounges, as well as an office and a quiet room. There are good sized gardens to both the front and rear of the property, and parking is available in the close. The home has its own transport. Care Homes for Adults (18-65 years) Page 5 of 28 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: For this inspection we (the Care Quality Commission) looked at all the information that we have received, or asked for, since the last key inspection of 4 Beech Close. This included: - The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in March 2010. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living at the home. It gives the manager the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live here. The AQAA also gives us some numerical information about the service; - Surveys which we sent to the home to give to people who live here: we received no replies; - What the service has told us about things that have happened in the home. These are called notifications and are a legal requirement; Care Homes for Adults (18-65 years) Page 6 of 28 - Any safeguarding issues that have arisen; - Information we asked the home to send us following our visit; and - Any other information we have received about the service offered to people at 4 Beech Close. This inspection of 4 Beech Close included a visit to the home on 14/04/2010. No-one who lives or works at the home knew we were going to visit on this day. We spent time talking to the people who live here, the manager, and some of the staff. We looked round the home and spent time observing what happens. We also looked at some of the paperwork the home has to keep including care plans, risk assessments, medication charts, and records such as staff personnel files, staff rotas, menus and fire alarm test records. The new manager, Regina Ncube, started working at the home since our last inspection and was registered with the Commission in January 2010. Care Homes for Adults (18-65 years) Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: We have confidence, from our discussions, and from her responses in the AQAA that the manager is aware of areas where the service should continue to improve. We have not made any requirements this time, however, areas where the service could do better include: - produce a statement of terms and conditions (contract) which service users and/or their representatives sign to show that they are clear about what they can expect from the service; - continue to improve the range and amount of activities, and the opportunities to develop independence skills, offered to the people who live here; - access NVQ (or equivalent) training for staff so that the whole staff team is qualified; and Care Homes for Adults (18-65 years) Page 8 of 28 - make sure the building, and the furnishings and equipment, continue to meet peoples changing needs. 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 28 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 28 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. There is good information available about what the home can offer, and peoples needs are assessed before they move in, so that people know the home can support them well. Evidence: 4 Beech Close has produced a statement of purpose and service user guide. The service user guide gives good information about the home, and was updated in March 2010. It tells people what they can expect from the home, so would give useful information to anyone thinking about moving here. The guide includes pictures and symbols, is written in large print, and uses easy-read language. We found a copy of the guide on the records we looked at. We looked at the records the home keeps about 2 of the people who live here. One person moved in since our last inspection. There was a good, detailed assessment on file of his needs, plus copies of the care plan and risk assessments from his previous home. The manager told us that staff had spent time with him at his previous home so he had familiar faces to meet him when he arrived, and staff knew about the care and Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: support he needs. This persons family lives locally so they had been able to help him settle. There was also a detailed assessment of the other persons needs, in his records. Each person (or their family) has signed a licence agreement with the Housing Association about their accommodation. However, the home has not developed a statement of terms and conditions (contract) which gives clear details about what the cost of care/support is, what the costs cover, what they have to pay for, what is expected of them and so on. The manager said the statement of purpose and service user guide cover this, however people (or their representatives) have not signed anywhere to say they understand and agree with the terms. One parent we spoke with said she has not received copies of the statement of purpose or service user guide, and does not know the details about what she should expect from the home. The manager agreed to look into this. Care Homes for Adults (18-65 years) Page 12 of 28 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. Support plans are clear and detailed, and give staff good guidance on the way each person wants to be supported. Risk assessments are carried out and medication is dealt with in a satisfactory way. Evidence: We looked at the support plans for these 2 people. The plans gave clear, detailed guidelines for staff for all areas of care and support needed by each person. The plans were person-centred, and written partly using I. The records were organised much better than when we last saw them, with most of the information now relevant and easy to find, and we noted that the plans had been reviewed regularly. Each person also has a PCP (person-centred plan) folder. The manager explained that Affinity Trust has realised that the program they use for this is far too complicated, with some if the information not applicable to the people who live in this service, so this is being re-done. Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: We looked at one persons life story file. This was full of photographs, from when he was born, through his life, including the different schools he had been to, and the homes he had lived in. There were lots of family pictures, and pictures of outings and activities. There was some information on the files to indicate that people are encouraged to make decisions about their lives, and our observations showed that people are involved in deciding some of what happens in the bungalow. Risk assessments had been completed about some areas of peoples lives, so that any risks could be minimised. For one person each risk assessment took into account that the person has seizures. One person had a communication passport on his file, giving good guidelines on the ways the person likes to communicate. The manager told us that she is undertaking a communication course, and a communication passport has been produced for the other person which will be put in place as soon as it has been approved. Staff write good daily notes which give a clear picture showing what the person has done, what sort of a day he has had, what he has eaten, and so on. Care Homes for Adults (18-65 years) Page 14 of 28 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. The staff team is working to improve the range of opportunities offered to people, both at home and out in the community, so that peoples lives are full, satisfying and interesting. Evidence: Each person has a weekly activities plan which gives staff an indication of what that person would like to do. The plan we looked at included a varied range of activities, both in the house and out in the community. However, these plans are not completed every week, and daily records showed that the plan is not always followed. The manager explained this is because people choose not to do some of the activities, or choose to do something else. Records showed that people do a number of different things: one person does something every day. The manager said the staff team are working on ways on improving the range and amount of activity each person is involved in. Care Homes for Adults (18-65 years) Page 15 of 28 Evidence: Staff told us that people are supported on a daily basis to work on their living skills, so that they can gain (or regain) some independence. For example, people help with household chores such as laundry, making their bed, hoovering and so on. People are supported to maintain contact with their families, and the manager told us that families are welcomed at the home. One relative we spoke with said she is not made to feel welcome by some of the staff. When we spoke to the manager she said she had become aware of this and was addressing it with the staff concerned. Mealtimes at 4 Beech Close are flexible, based on what each person is doing. Usually people have cereals and toast for breakfast, a light lunch and a main meal in the evening. We looked at some of the menus and saw that a nutritious, balanced and varied diet is offered, based on what people have indicated they like to eat. A lot of fresh fruit, vegetables and salads are included on the menus. One of the staff said they all take it in turns to cook, and people are offered an alternative meal if they do not like what is on the menu. Care Homes for Adults (18-65 years) Page 16 of 28 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. People are supported with their personal care in the way they prefer, their health needs are met and staff administer medicines correctly and safely. Evidence: Support plans and daily records show that staff offer personal care in the way people have shown they prefer. Each person has a completed Health Action Plan (HAP) which gives a lot of detail about the persons health and healthcare needs. The plans had been reviewed and revised where necessary. We saw evidence that people are supported to see a range of other healthcare professionals such as dentist, optician and so on. One persons file showed that he had had several appointments about his hearing. Each person has a medication file. One we looked at had clear guidelines for the administration of when needed (PRN) medication. We checked medication administration record (MAR) charts and noted they had been completed correctly, and that audits had been done to make sure the right number of each medicine remained. The person most recently admitted had arrived with instructions from his consultant that his tablets were to be crushed and added to food. Recently, his new consultant Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: had changed some of the medication to liquid form, and had advised the home to seek advice from the Mental Capacity Act coordinator, which the manager had done. Care Homes for Adults (18-65 years) Page 18 of 28 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know that their concerns will be listened to and acted on, and that staff are trained to keep them safe from harm. Evidence: The home has a complaints and compliments procedure, which includes a number of people within the organisation that the people living at 4 Beech Close can contact if they want to make any comments about the service. The procedure also included the correct details for contacting CQC. We advised the manager that details of the adult social care team should also be in the procedure as it is that team which would investigate any complaints made by, or about, an individual person. The procedure is written in easy-read language and includes pictures, photographs and symbols. People who live here need support to manage their money. The relatives of 2 people handle their finances. Affinity Trust is applying to the Court of Protection so that the other person can have access to his money. A small amount of cash is kept in the safe for each person so they have money to spend if they want to go out or go shopping. A sealed pouch system is used so that the cash and balance are checked to be correct each time money is taken out or put in: the manager checks the maths as well as the balances, regularly. We looked at the records for two people: one was absolutely accurate; the other was 1p out. People pay for all their activities, including the transport, and the home pays for any staff expenses. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: According to the training records, and staff we spoke with, all staff have had Safeguarding of Vulnerable Adults (SOVA) training and would know what to do if they suspected any abuse was going on. In the AQAA the manager said that 4 referrals had been made to the SOVA team in the past year. On the day we visited, the manager was talking to the SOVA team about one person who had had a seizure 2 days previously and fallen out of bed. A large bruise had developed on his shoulder, and he was indicating it was still uncomfortable. One relative we spoke with after the inspection raised some concerns, which we have referred to in other sections of this report. We have written to the manager about these, and asked her to deal with the issues raised. Care Homes for Adults (18-65 years) Page 20 of 28 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. 4 Beech Close offers a comfortable, clean and reasonably well maintained home which suits the people who live here. Evidence: The home was completely re-furbished before being opened in January 2009. A small amount of re-decoration had been done since our last visit, and generally the home was well decorated and quite comfortably furnished. We looked round the home and found everywhere to be clean and tidy with no unpleasant odours. All 3 people who live here have autism so have found some things in the environment difficult to tolerate. It has taken staff a long time to introduce new things, such as pictures, around the home. However, staff had recently put some very good photographs, of the people who live here, in the dining room near where each person chooses to sit. Each bedroom is as personal as the person wants it to be. On the day we visited, the manager explained that she was trying to get some improved monitoring equipment for one person who needs to be supported through seizures that happen at night. The equipment in place was proving to be inadequate for his needs. Following the inspection, the manager told us that the equipment is now in place. Care Homes for Adults (18-65 years) Page 21 of 28 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 people who live here benefit from staff that are recruited well, and who have sufficient training, supervision and support so that they can do their jobs properly. More staff should be given the opportunity to work towards a qualification. Evidence: The staff we spoke with told us that they enjoy working at 4 Beech Close. One said Its an absolutely excellent team. Staff said These guys are very well looked after.....a lot of the staff go that extra mile. The manager said that now there are 3 people living here, she tries to have 4 staff plus herself on duty during the day. This gives people opportunities to go out. However, she said people are still safe with 3 staff and the manager. There are 2 waking night staff. We looked at the personnel files of 3 members of staff. All the information the home has to have before the staff member can be employed (such as two references, a Criminal Record Bureau (CRB) check, proof of identity and so on) were in the file. We noted that for one person their leave to remain in the UK had run out. However, there was evidence at the organisations head office (which was faxed to the home when we asked for it) to show that the person had completed their visa application Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: correctly and all was in order. On the files we looked at, we found evidence that all staff undergo a thorough induction programme which is completed over a period of about 3 months. The staff training matrix showed that all staff are up to date with all the mandatory training (moving and handling; food safety; infection control; first aid) except perhaps fire. We advised the manager to check with the fire authority what their requirements and recommendations would be about how often, and in what form, staff should have training in fire safety. Staff have also been offered a range of other training courses: one staff member told us Training is spot on - I cannot fault it. They had done courses on topics such as autism; challenging behaviour; and the Mental Capacity Act, as well as all the mandatory topics, including SOVA. One staff member had been awarded a National Vocational Qualification (NVQ) in care level 3, a GNVQ in health and social care, and had completed the Learning Disability Award Framework (LDAF). In the AQAA the manager told us that only 4 of the 15 permanent staff have been awarded an NVQ. This is not good enough and we have recommended the organisation accesses NVQ (or equivalent) training for all staff. Staff told us they have regular supervision with either the manager or the deputy manager, and staff meetings are also held monthly. Supervision notes on the files we checked showed that supervision is held very regularly. One of the staff said Theres no problem with management - very supportive. One of the relatives we spoke with said that communication over the telephone with some of the staff can be quite a problem, because some staff have very heavy accents. This person also said that staff are not very communicative when they arrive at the home. The manager told us she is working with the staff to improve this. Care Homes for Adults (18-65 years) Page 23 of 28 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. This home is managed well, and the manager is aware of further improvements that can be made, so that the quality of life for the people who live here will continue to get better. Evidence: The manager, Regina Ncube, took up her post in mid-2009 and was registered with CQC in January 2010. Mrs Ncube has worked in various care settings for a number of years. Staff told us the manager is very supportive. The homes quality assurance system includes a number of ways to ensure the quality of the service offered to the people who live here is of a high standard. Written surveys are given to the people who live here, and their relatives, and staff have also been asked for their views. All responses are put together into a report by head office. The organisation carries out a key outcome audit every 3 months, and visits required by regulation 26 of the Care Homes Regulations are carried out monthly. We looked at some of the records the home has to keep. As well as other records we Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: have discussed in other sections of this report we also noted that notifications required by regulation 37 (about any events that affect the well-being of people who live here) are sent to CQC and regulation 26 reports of visits made to the home by the provider were available. The emergency lighting and fire alarm systems are tested regularly as required. All staff should be involved in a fire drill at least once a year. The manager said all staff are up to date with training in all the topics relating to health and safety, that is moving and handling; first aid; infection control; and food hygiene. (See Staffing section of this report, regarding fire safety training). Staff we spoke with confirmed this. Care Homes for Adults (18-65 years) Page 25 of 28 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 28 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 5 A statement of terms and conditions (contract) should be agreed with people (or their representative), so people know what service they should expect. The staff team should continue to improve the range and amount of activities and opportunities for independence available for people to choose from. The manager should make sure the building, and the furnishings and equipment, continue to meet peoples changing needs. Staff should be given the opportunity to work towards gaining a qualification. 2 12 3 29 4 32 Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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