Care Home: Amber House

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What the care home does well The service continues to provide the people living in the home the opportunity to take part in a wide range of activities. Their choice and preferences are promoted and they are well supported to make daily life decisions. Feedback from the postal surveys was positive and people who use the service comment: `The home does well with the crafts, cooking, painting, puzzles, going out shopping or for coffee and keeping me busy`. `I like the food, outings and barbecue`s in the summer`. What has improved since the last inspection? All staff have NVQ 2 or above and are qualified and experienced to meet the people`s needs. The home has taken up the Dignity challenge which means they will continue to exercise the rights of the people, their personal safety, give support when required and treat them with dignity at all times. What the care home could do better: When asked what the home could do better a person living there comments. `Nothing that I can think of`. We found that the assessments and support plans do not always show clear recording of current information. The plans do not identify clearly, what, if anything, has changed when the plans are reviewed. Improvements are required to make sure that all staff have a current Criminal Record Bureau and Independent Safeguarding Authority checks in place. Training records do not clearly reflect what training has been provided to the staff. We found that although there is informal staff supervision, improvements are required to made sure that staff supervision is recorded. Key inspection report Care homes for adults (18-65 years) Name: Address: Amber House 33 Shorncliffe Road Folkestone Kent CT20 2NQ     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: Penny McMullan     Date: 0 7 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 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) © 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 27 Information about the care home Name of care home: Address: Amber House 33 Shorncliffe Road Folkestone Kent CT20 2NQ 01303254459 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): colnswaffer@aol.com Mrs Maryanne Swaffer,Mr Colin Swaffer Name of registered manager (if applicable) Mrs Maryanne Swaffer Type of registration: Number of places registered: care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 3 The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category : Learning disability (LD) Date of last inspection Brief description of the care home Amber House was first registered on 26th July 2004. It provides accommodation and personal care for a maximum of three service users who have learning disabilities. The building is suitable to those who are physically mobile within the home environment. Situated on the Shorncliffe Road area of Folkestone, it is ideally placed for access to public transport, with rail and bus stations being approximately 10 minutes walk away. The local Adult Education Centre and South Kent College are a Care Homes for Adults (18-65 years) Page 4 of 27 Over 65 0 3 Brief description of the care home very short distance and the main shopping centre of Folkestone is around 15 minutes walk. Pleasant gardens and walks overlooking the sea are within easy reach. Accommodation is provided on the ground and first floor. There are two communal toilets, one communal bathroom and one, currently unregistered, bedroom has a full en-suite with shower facility. Communal space comprises of a large lounge / diner and domestic kitchen. There is an office space with laundry facilities to the side of the premises. A reasonably sized, secure rear garden with patio is accessible for all service users. The fee for the home ranges from £800 to £1025 per week. For more information about the fee and what it includes please contact the Provider. 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: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was carried out over a period of time and concluded with a visit to the home on 7th April 2010 between 08.30am and 3.30pm. The last key inspection was carried out on 30th April 2007. Ten postal surveys were forwarded to the home to distribute to the people who use the service and staff. Three surveys were received from the people who use the service and one from staff. Comments made in all of the surveys have been included in this report. We spoke to the Registered Providers, staff and the people living in the home. We looked at individual support plans, risk assessments and daily records including medication documents. We also looked at staff files and training records. A partial tour was made of the home including the communal areas and two bedrooms. The atmosphere in the home was calm and relaxed and everyone was happy to discuss the Care Homes for Adults (18-65 years) Page 6 of 27 visit. The Annual Quality Assurance Assessment (AQAA) that was sent to us by the service was clear and comprehensive. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. The home returned the Annual Quality Assurance Assessment (AQAA) within the required timescale. The owners of the home, Mr and Mrs Swaffer, continue to manage the home and are part of the staff working rota. They have been referred to in this report as the Register Providers. Mrs Swafer manages the home and is also referred to as the manager. 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 using the service can be sure that the home will be able to meet their assessed need and aspirations. Evidence: Information about the home is available and people who may be thinking about coming to live in the home are encouraged to visit and get familiar with the people and staff living there. The Service User Guide is available in picture format and large print to make sure people have an understanding of the service. This information is also available on CD. The last person to come and live in the home visited several times, met the people living there and staff. It took a while for her to make up her mind, during which time she took pictures of her bedroom and the house in general to help her make the final decision. The manager carries out a care needs assessment which forms part of the support plan. We found that it is not completely clear in the plan what part of the document is Care Homes for Adults (18-65 years) Page 10 of 27 Evidence: the initial assessment as it is not a separate document. The manager of the home told us that a she will improve the documentation to clearly evidence the assessment process. We saw information from social services and health care professionals to make sure that the home has detailed information to meet the persons needs. Care Homes for Adults (18-65 years) Page 11 of 27 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home have individual care and support plans that identify their needs and personal goals. They are supported in taking risks as part of an independent lifestyle. Evidence: We found that all of the people have a person centered support plan. We looked at two plans which contained detailed information on each individual, showing what they could achieve themselves and when they needed support. Daily records contain details to show how the people have made choices and decisions and what they have decided to do each day. People have access to and use independent advocacy services to assist and support them in making their decisions. Through observation, and listening to the people living in the home and staff there was evidence to support that the people in the home are actively involved in the day to day running of the service. Care Homes for Adults (18-65 years) Page 12 of 27 Evidence: One person was supported to prepare the lunch and was seen helping with the cooking and daily chores in the kitchen. The people were asked what they wished to do or what they had decided to do. Any limitations and restrictions are recorded in the support plan. We saw that the staff were patient and listened while the people made up their minds to do what they wished to do. They were able to effectively communicate with each individual person living in the home. Risk assessments are recorded in each support plan. They are used to make sure the people can take their own reasonable risks. The risk assessments contain control measures so that staff are aware of what they must do to minimise the risk. Care Homes for Adults (18-65 years) Page 13 of 27 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are encouraged and supported to have the lifestyle they choose and are able to take part in a range of activities of their choice. They are supported to maintain family relationships and enjoy a balanced healthy diet. Evidence: Each person living in the home has a key worker who supports them with their activities and daily living choices. A weekly meeting takes place to discuss what each person would like to do and they also discuss and choose the menu for the week. The support plan details the preferred hobbies and activities for each person and an individual activities plan is in place to make sure they are able to fulfill their wishes. The plans include outcomes to be achieved, for example one plan shows how the staff will be encouraging a person to try new things to help her gain more confidence and be as independent as possible. Pictures are used to make sure the people are able to Care Homes for Adults (18-65 years) Page 14 of 27 Evidence: understand what is in their plan and identify what they wish to do. The activity plans had just been reviewed to make sure that the people are still happy with their plans and record any new activities they may wish to do. One person told us how she enjoyed clothes shopping and going to the supermarket. We saw staff supporting and encouraging the people to take part in activities, completing puzzles and getting ready to go out to the supermarket. Various activities are provided including, key board skills, pottery, art class, cooking, sewing, puzzles, card making, playing board games, and gardening. The people are also supported by staff to attend religious services of their choice. The people are encouraged and supported to maintain contact with their family and friends. One person was going out to lunch with her relative at the time of the visit and family members are welcomed in the home. The manager told us that there is good family support from relatives and if required they are involved in the support plans to make sure that the person needs are fully met. Advocacy services are available and currently one person is being supported to make decisions about her life. This means that everyone is given the opportunity, if they wish, to receive independent help to make up their own minds about their life. Everyone in the home is involved in the daily routines, including the cooking and general tidying of their home. One person works in the kitchen on a regular basis and is supported in the preparation and cooking of the meals. At the time of the visit she was supported to prepare vegetables and make cakes for tea. She was observed choosing and getting the vegetables from the fridge, and getting the right colour chopping board to use. We also overheard her being supported to discuss the meal with the other people in the home to make sure they were happy with the choice. All of the people have access to the kitchen and there are snacks and fresh fruit available if required. Meals are chosen by the people living in the home and staff make sure that their diet is balanced and healthy. Any dietary needs, likes and dislikes are recorded in the support plans. The lunch looked apetising with good portions and the people said they enjoyed it and the food is good. The home has a very inclusive atmosphere and staff make sure that everyone is included when discussions are taking place. Care Homes for Adults (18-65 years) Page 15 of 27 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home are supported to have their personal and health care needs met. Their support is flexible, promoting privacy, dignity and control over their lives. Evidence: Personal care and health care needs are detailed in the support plan for each person. Staff work well with the people to make sure they are aware of their health care needs and pictures are used to help them understand better. The plans show that the people are supported to be as independent as possible by recording what encouragement they need and what they can achieve for themselves. The home has introduced a passport of me document. The people using the service help to choose pictures to detail their care needs, choices, medical conditions and all aspects of their lives, including choices and preferences. Once completed the passport clearly outlines what health and social care needs are required for the individual. The plans also include behaviour guidelines and risk assessments which give staff direction of how to keep the people safe. There is also specific information with regard to eating and drinking, including likes and dislikes. Care Homes for Adults (18-65 years) Page 16 of 27 Evidence: All health care needs are monitored and recorded, including hospital out patients appointments, doctors visits, chiropodist and optician requirements. The home work well with health professionals to ensure health needs are met. There was evidence to show that specialist support is obtained when it is needed and the home does everything possible to make sure the needs of the people are met. We saw that one person had contact with the speech therapist, psychologist and the local learning disability team. The support plans had been updated and reviewed. They are reviewed by the manager, dated and signed, however the information is not always clear as to what, if anything, has been updated or changed. Improvements are, therefore, required in the support plans so any changes can be clearly identified by staff. Medication storage is adequate and the majority of the drugs are supplied in pre packed trays from the pharmacy. This means that the medication is administered to people more safely as it has been pre-packed by the pharmacist. Records of receipt, administration and disposal are in place and medication requirements are also recorded in the support plans. The medical record sheets show that staff sign each time they administer the medication and there were no gaps in the recording process, however it is good practice to counter sign any hand written medication requirements. The manager told us that all staff administering the medication have received the appropriate training. Staff were observed treating the people with respect and dignity, supporting them to make their daily decisions and decide what they wanted to do or where they wanted to be in the home. The staff know the people living in the home well. It is a family run home and the people living there are actively encouraged in the day to day decisions of when to get up, go to bed, meal times and joining in with activities. Care Homes for Adults (18-65 years) Page 17 of 27 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a satisfactory complaints system and people living in the home are protected from harm and abuse. Evidence: The complaints procedure is on display in the hallway and is in the process of being updated with the CQC address. There is a complaints log in place, however there have been no formal complaints since the previous inspection. The manager told us that they would know if the people living in the home are unhappy as they are part of the working rota and regularly monitor the standard of care being provided. The majority of staff have received safeguarding adults training and have covered this as part of the NVQ awards. One member of staff is updating her training in April. Staff are aware of their own safeguarding polices and procedures and who to report to if there are any issues or concerns. There is currently involvement of advocacy services in the home to make sure that people are supported to make their own decisions. The service has records to demonstrate that peoples finances are protected and managed safely. There are some concerns with regard to checks made on staff to make sure they are safe to provide the service. Further details are in the staffing section. 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 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 maintained to a high standard making it a very homely and pleasant place to live. Evidence: The home is clean, tidy and well maintained. There is a very homely atmosphere and a garden where the people can grow their own vegetables and plants. This can be accessed from the lounge and there is also a patio with seating. There is a front garden with parking available. The Registered Providers are planning to apply to the Commission for another bedroom to be to the registered, provide a walk in shower on the ground floor and convert the garage to provide a larger space for activities. We saw two bedrooms which were personalised to individual choice. Bathing and toilet facilities meet the needs of the people and any equipment to support the people needs is in place. The laundry is in a domestic setting and there are systems in place to reduce the risk of infection. Care Homes for Adults (18-65 years) Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home can be confident that their full care needs will be met by consistent staffing levels. Improvements are required in the training records to evidence that the staff have received the identified training to do their jobs well. Evidence: The Registered Providers and a team of three staff support the people living in the home. There is currently no formal rota in place, although it is recorded who is on duty. The owner said that she would implement a rota as soon as possible. Support is provided in a family run person centred way with all included in the day-to-day activity. We looked at all of the staff files and found that the Criminal Records Bureau (CRB) checks had not been carried out properly. We found that the CRBs were not up to date and the Registered Provider had to ask the staff to produce a copy of their CRB checks to make sure they were current. This resulted in two members of staff producing the required documentation. The other member of staff did not have a current CRB. The one on file showed that the check was made from her previous employer and was dated 2002. An Immediate Requirement and Code B Notice was issued to make sure that the Registered Provider takes immediate action to rectify this Care Homes for Adults (18-65 years) Page 20 of 27 Evidence: situation. A letter will also be sent to the Registered Providers to make sure that they provide evidence to confirm that immediate action has been taken to address this issue. A Code B Notice is a document which is the first step of our enforcement pathway which may lead to further enforcement action being taken. The form also tells the service their rights. The Registered Providers did take action at the time of the visit and arranged for the CRB application form to be sent to the home for the member of staff apply for a CRB. All other checks on staff, for example, two written references and proof of identity are in place. Application forms and full background details have been completed however the application form requires updating in line with current legislation. The Registered Providers told us they would contact their employment support services for this to be amended. The manager told us that mandatory training had been provided for the staff however records did not reflect this. The individual training forms did not show that training was up to date. For example moving and handling had not been updated and some first aid training was also not up to date. The manager told us that they are in the process of arranging for this training to be updated. They are also looking into updating fire awareness training for all staff. Some specialist training has been provided. The Registered Providers have received Mental Capacity training and the rest of the staff will be receiving this training in the near future. There is evidence that one member of staff has received Equality and Diversity Training, risk assessment and dementia care. Training records would benefit from a thorough audit to clearly show what level of training has been given to all staff. Induction training is in place and staff competencies are checked. The manager told us that new staff shadow her for two weeks before they commence their full duties. This is to make sure they have the skills to do their jobs well and get to know the people living in the home. The Registered Providers have a thorough knowledge and understanding of the peoples needs and continue to monitor the standard of care being provided. All of the staff have NVQ 2 or above and are experienced carers. Records showed that staff have received an appraisal but supervision was not fully up to date. The Registered Provider told us that informal and observational supervision takes place regularly as they both work with the staff as part of the duty rota. Staff work consistently with the Registered Providers and discuss any issues when handing Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: over after each shift or at staff meetings. We were told that, in future, all supervision will be recorded to evidence that this has taken place. Care Homes for Adults (18-65 years) Page 22 of 27 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and run in the best interests of the people living there. The health and safety of the people and staff is protected. Evidence: The Registered Provider Mrs Maryanne Swaffer is qualified and experienced. She continues to manage the home and be part of the working rota. She has a thorough understanding and knowledge of the people living in the home and meeting their needs. Both the Registered Providers work throughout the week in the home and work with the staff team to make sure that a high standard of care is being delivered to the people who live there. People living in the home were relaxed and confident when speaking to the Registered Providers and staff. Despite the shortfalls identified in this report the outcomes for the people living in the home remain very good. They are consulted every day with regard to the running of the home, their meals and activities, what they would like to do and how they would Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: like to do it. There are weekly meetings and each person is given the opportunity to discuss any concerns or issues. There is currently no formal quality assurance programme in place however it is evident that the people in the home and their relatives are consulted about the service. The manager told us that questionnaires have been sent out to other stakeholders in the past and they will be looking at ways of getting professional feedback from visitors to the home. They discussed ways of using pictures and other formats to evidence that people are happy with the service. They told us that this would be addressed and formal records will be put in place. The AQAA shows that all relevant safety checks have been carried out in the home and the recent fire and rescue officer visit did not raise any concerns. The home has a fire risk end environmental risk assessments in place and accidents and incidents are recorded. 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 1 34 19 The Registered Provider to 15/04/2010 make sure that all staff have a current enhanced criminal record certificate in place and that checks have also been made with the Indpendent Safegaurding Authority. To make sure that staff have been appropriately checked and are safe to provide care to vulnerable people. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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