Care Home: Ambleside Avenue, 15

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What the care home does well There are several areas where the home does well, and two areas where it excels: - a thorough assessment is carried out on potential service users prior to placement and ample opportunities to trial the home are given - care plans are regularly reviewed and daily diaries are kept for individual service users that evidence whether care plans are being put into action - the home provides an excellent range of activities for service users and ensures that they have regular access to the local community - daily routines are flexible and service users are not rushed when attempting tasks or having meals - the home is purpose built, well fitted and furnished, and provides ample space and choice of space for service users - staff qualifications far exceed the recommended standard, and staff treat service users with dignity and respect - the Registered Provider provides a thorough induction programme and a wide range of on-going training What has improved since the last inspection? The home had implemented all of the requirements and recommendations of the previous key inspection of 23rd October 2007. What the care home could do better: There were no requirements arising from this inspection, and only 2 good practice recommendations - that risk assessments are checked to ensure those no longer relevant are removed from files so that it can be clearly seen the all those remaining have been reviewed as appropriate, and that staff record the actual time that fire drills take place. Key inspection report Care homes for adults (18-65 years) Name: Address: Ambleside Avenue, 15 Ambleside Avenue, 15 Streatham London SW16 1QE     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: Rehema Russell     Date: 0 7 0 7 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 29 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 29 Information about the care home Name of care home: Address: Ambleside Avenue, 15 Ambleside Avenue, 15 Streatham London SW16 1QE 02087699723 02087726223 reception@southsidepartnership.org.uk www.southsidepartnership.org.uk Southside Partnership care home 6 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: To include two persons aged 65 years and above Date of last inspection Brief description of the care home 15 Ambleside Avenue is a detached purpose built house designed to provide support and accommodation for six people who have learning disabilities. The building is owned by Amicus Horizon Group and the service is managed by Southside Partnership, a voluntary organisation. The property is wheelchair accessible with wide internal corridors and room entrances, a lift, and ramp to the front entrance. There are six single bedrooms, all above minimum space standards. The ground floor has two bedrooms, a lounge, a large kitchen/diner, bathroom with shower and a separate toilet. The first floor has four bedrooms, a bathroom with toilet, a separate toilet, an office, laundry room and storage cupboards. There is a small garden and the home is within easy walking distance of a large shopping area with full community facilities, bus and rail transport, and a large public common. More detailed information about the services provided can be found in the home?s Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 0 6 6 Brief description of the care home Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the home. Care Homes for Adults (18-65 years) Page 5 of 29 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 unannounced inspection was undertaken by one inspector on 7th July 2009. The inspector toured the premises, spoke in depth to two support workers and the Manager, spoke in general to 2 other support workers, spent time with service users, spent time observing the interaction between service users and staff, and looked at documentation and records. The home had not been asked for an AQAA (Annual Quality Assurance Assessment) prior to this inspection, but it had been asked for one in August 2008 and had returned it promptly and in good detail. Care Homes for Adults (18-65 years) Page 6 of 29 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 7 of 29 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 8 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users individual aspirations and needs are fully assessed prior to placement and they are given several opportunities to visit and experience the home. Evidence: Although the majority of service users have been at the home for several years, a new service user was admitted in late September 2008 and this persons care file was looked at to check the admission procedure followed by the home. It demonstrated that the home had obtained all relevant documentation from the previous placement and from the placing authority, and had carried out a full and thorough assessment. Staff had also ensured that the care needs highlighted by the assessment process, such as seeing the speech and language therapist, seeing the occupational therapist, having a pressure sore risk assessment and having a holiday, were all progressed soon after placement. The placing authority Placement Review which took place 2 months later stated staff show motivation to meet (name)s needs and appear to relate to her with respect and care...(the home appears to be) experienced in caring for elderly frail residents. Documentation also demonstrated that there had been a lengthy trial period before Care Homes for Adults (18-65 years) Page 9 of 29 Evidence: the service user was admitted to the home, involving more than 4 visits to the home over a period of months, to ensure that the home would be able to meet their needs and that the service user felt familiar and comfortable with staff and other service users. Care Homes for Adults (18-65 years) Page 10 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users assessed and changing needs and personal preferences are reflected in their individual plans, and staff determine their likes, dislikes and choices by interpreting their behaviours and using key words and objects of reference as appropriate Risk assessments are clear and the majority have been regularly reviewed. Evidence: Two care files were checked. Both had person centred Communication Passports, with photographs and clear and simple guidelines of how to communicate with me. Care plans had 3-5 different components, such as support, activities, objects of reference, relaxation/holidays, domestic chores, hair care etc., and each had been reviewed monthly. Annual reviews by the placing authority, including attendance by the key worker, manager and family members, were also present on file. In addition to these forms of review, each service user has their own diary book where staff enter every activity undertaken on a daily basis. in these ways staff ensure that service users needs and wishes are understood and met. Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: The service users at this home have profound learning disabilities and very little or no verbal communication, and so their ability to express choice is limited. Staff therefore try to consult with them and determine their choices by interpreting their body language and their reactions Some service users understand key words or objects of reference and so these two forms of communication are also used. Observation of staff interacting with service users confirmed the use of these methods, and the very low incidence of challenging behaviours indicates their success. Risk assessments were present on files, clearly written and with easily understood sections on action to be taken. They covered areas such as epileptic seizure, choking when eating or drinking, fire in the house, fire in holiday apartment and physical accident. The majority were regularly reviewed but one seen was due to be reviewed earlier in the year and had not been. However, as old and no longer needed risk assessments were still present on file (such as those relating to holidays taken in the previous year), the one not reviewed may be on that is no longer needed. It is therefore recommended that all risk assessment sections are checked to ensure that only relevant risk assessments are present and that all of those have been reviewed. See Recommendation 1. Care Homes for Adults (18-65 years) Page 12 of 29 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. Service users mental, emotional and physical care needs are supported. They are enabled to take part in a variety of appropriate activities, to be part of the local community and to maintain family relationships and friendships. Service usres are offered a healthy diet and their choices are respected. Evidence: Service users are given opportunities to develop social, emotional and independent living skills within the limitations of their learning and physical disabilities. Service users are encouraged to eat together in the dining room, to undertake activities at colleges and in the community and to practice daily living skills such as tidying their rooms, clearing the table, helping with their laundry and feeding the fish. One service user was observed to be supported to apply her prescribed ointment for herself. Two service users are supported to attend the nearby Church on Sundays. Staff enable service users to take part fulfilling activities by encouraging and Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: supporting them to attend classes at a local college according to their individual preference and abilities. These classes include keep fit, music, aromatherapy and creative expression. Service users are also taken on individual outings by their key workers, such as collecting their own prescription, shopping, going to the cinema and going for a walk. On the day of inspection one key worker took his client to Dean City Farm. Inside the home, service users have games and sensory equipment, music and music-making objects and listen to stories. One service user, who is blind and deaf, has specialist audio equipment in her room so that she can enjoy music via vibrations and also has other sensory objects that she can enjoy. Service users participate in the local community via trips to the shops, cafes, cinema, pubs, parks and funfairs. Other social activities include annual holidays, barbecues and attending the registered Providers social club. The home encourages and supports service users to maintain family and friendship links, although currently two service users do not have any family contact. Staff are trying to get one of these service users a befriender from a relevant organisation. Of the other three service users, one has a weekly visit from a brother, one has a weekly visit from a friend and the third has occasional visits from their brother and sister. Daily routines are flexible and promote individual choice and freedom of movement. On the day of inspection service users were observed to move freely around the home, choosing where they wished to be at any time. One service user spent some time at the breakfast bar in the kitchen as she likes to observe any cooking that is going on. Others moved between the lounge and kitchen-diner as they wished. In order to enhance the independence of one service user who has severe auditory and visual disabilities, objects of reference had been attached to her bedroom, nearest bathroom, lounge and dining room. Staff said that one service user is able to pick out the clothes she wishes to wear each day and that another can choose between two items, such as shoes or nightdresses, when staff present them to her. The way that staff are able to interpret the body language and therefore choice of service users was demonstrated when one support worker read out a story to 4 service users in the lounge. One service user made eye contact with the support worker and smiled, one listened then put her fingers to her ears, one stopped make her usual noise, listened and responded positively when shown pictures, and the fourth listened for a while then got up and walked away. Menus were seen and showed that service usurers receive nutritious food and a balanced diet. Although they cannot verbalise, service users preferences are well know to staff and they can express their choice through body language or refusing to eat. Alternative meals are available and recored in a book kept for that purpose examples seen were when service users have had a Chinese take-away, a house party or chicken rather than beef stew. Pictures and photos supplement the menu display making it more accessible and meaningful to individual service users. On the morning Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: of the inspection three service users were still having breakfast when the inspector arrived, one feeding herself and the other two being assisted discreetly by staff. The atmosphere was relaxed and pleasant and service users were not rushed. However, staff feel that the 4 weekly menus are rather repetitive and so the whole team were going to discuss the menus during the week to ensure that they are varied as well as nutritious. Care Homes for Adults (18-65 years) Page 15 of 29 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. Staff provide sensitive and flexible personal support and ensure that service users physical and emotional health needs are met. service users are protected by the homes pl policies and procedures for dealing with medicines. Evidence: Observation and verbal evidence demonstrated that staff carry out personal support sensitively and in a way that ensures service users privacy and dignity. Staff spoken with were familiar with the behaviours and preferences of the service users they key work and demonstrated how service users are enabled to make choices in regard to daily routines and activities. Service users were well groomed and age-appropriately dressed. Case files and the appointments book evidenced that staff seek specialist support and advice from general practitioners, occupational therapists, hospital consultants and others, as service users needs arise or change. Documentation and verbal evidence from staff also demonstrated that residents are supported to access the full range of health care professionals, including the general practitioner, district nurse, dentist, chiropodist and physiotherapist. Each service user has an individual health action plan with comprehensive information relating to their Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: health care needs, and a record of appointments and contacts is kept for each individual service user. The storage, administration and recording of medication was checked and no problems were found. The inspector observed a support worker administering medication to one service user and this was done in a way to maximise her independence. A weekly medication audit is carried out at the home so that any errors or potential errors can be spotted as soon as possible, which is good practice. Care Homes for Adults (18-65 years) Page 17 of 29 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 complaint procedure is clear and thorough, and is available in a form suitable for service users cognitive abilities. Th Manager an staff act appropriate to ensure that service users are protected from abuse, neglect and self-harm. Evidence: No complaints have been received by the home or the Commission since the previous inspection of 23rd October 2007. The complaints procedure for the home is n an appropriate form for service users wit learning disabilities and is also available in audio form for service users with visual impairment. the procedure is available in the Service User Guide, in a suitable format. Staff spoken with displayed a good knowledge of abuse issue and how to deal with the. Th Manage an staff spoken with were familiar with the steps to be taken in the event of suspected abuse and the home holds a copy of the local authorities Vulnerable Adults Policy. Care Homes for Adults (18-65 years) Page 18 of 29 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. Service users live in a homely, comfortable and safe environment. Bedrooms reflect their individual needs, preferences and interests and specialist equipment is provided to met their needs and enhance their independence. Communal areas and comfortable and homely and the home is clean and hygienic throughout. Evidence: The homes premises is purpose-built and suitable for its stated purpose. There is a ramp up to the front door and a lift to the first floor, so that the home is suitable for people in wheelchairs with or with other mobility restrictions. It is accessible, safe and well maintained, and comfortable and homely inside. All bedrooms are larger than minimum standards and can accommodate wheelchair users. Staff have ensured that each bedroom is comfortably furnished and personalised to reflect the individual service users interest and choices. This includes possessions that are meaningful to each person such as music CDs, certificates, soft toys and family photographs. Staff have also ensured that each service user had the equipment and aids to meet their current needs, such as wheelchairs, hoists, rails and adapted beds. This ensure that service users self-esteem and independence is supported and encouraged. The two indoor shared spaces for service users are the lounge and the dining area of the kitchen-diner. The lounge is attractive, comfortable and homely, with good quality Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: furniture, furnishings and fittings, and the dining area is also attractive and homely, with potted plants, ornamentation and several seating areas. Observation of service users suggested that they were comfortable and relaxed in both of these rooms. On the day of the inspection the home was found to be meticulously clean and hygienic throughout, with no offensive odours. Care Homes for Adults (18-65 years) Page 20 of 29 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. Service users are supported by competent and qualified staff, who are well trained. Service users benefit from well supported and supervised staff and are protected by the Registered Providers recruitment policy and practice. Evidence: Of the current 8 daytime support workers, 5 have NVQ Level 3, 2 have NVQ Level 2 and are beginning NVQ Level 3, and the remaining support worker has just started at the home and so will be starting NVQ Level 2. Both night workers have NVQ Level 4. The home has therefore far exceeded the recommended qualification standard. Staff spoken with were familiar with the needs, characteristics, preferences and behaviours of service users and understood the particular care needs of the service users the key worked. They demonstrated sensitivity to service users cognitive and physical disabilities and a commitment to their independence, choice and rights. Service users appeared to be relaxed and comfortable in their presence, and reacted positively to staffs suggestions and humours. A comment seen in a local authority placement review form written in February 2009 said I fell (name) is placed in a home appropriate to her needs, staffed with people who appear to be experienced supporting elderly frail residents. The newest support worker, who had joined the hoe in December 2008, described in detail the recruitment procedure that the Registered Person had followed. This was Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: thorough, based on equal opportunities and ensuring the protection of service users, and met all of the requirements of legislation. In addition, the support worker had a second interview which involved a visit to this home to meet the service users and support workers on shift, which means that she had been given an insight into the needs of the service users before she made up her mind about the job, which is good practice. The inspector was unable to check actual staff recruitment records as these are held centrally at the Registered Persons headquarters, however the Manager had a full list of up to date CRB disclosures for the staff team. In addition, the new member of staff spoken with confirmed that a POVA First had been attained y the Registered Person before she was allowed to start work, supervised, at the home. The newest member of staff confirmed that there is a structured induction programme that covers all basic mandatory training and in addition includes training relevant to the client group. For example, on the day prior to the inspection she had attended training in autism, medication and older peoples mental health. In regard to on-going training, the Registered Provider has a very thorough and comprehensive training programme, incorporating in-house and external courses, which is also available to bank and agency staff. All mandatory training is updated quarterly, and a range of other relevant training is available throughout the year. The diary showed that relevant training such as person centred active support and fire training had been carried out within the last few months, and the Manager told the inspector that he and the senior support worker were about to do Mental Capacity Act training soon. Staff confirmed that staff meetings are held fortnightly. The Manager said that the frequency of staff metings was to encourage creativieyt, so that staff could be kept up to date with the changes occurring in the provider organisation, and so that there was time to discuss service users care in depth. Members of staff spoken with confirmed that they felt able to express themselves openly at team meetings and ask whatever questions they wished. Team meeting minutes were seen and demonstrated in depth discussions of service users needs with the aim of progressing their care. Staff also confirmed that they receive regular supervision. Care Homes for Adults (18-65 years) Page 22 of 29 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 Manager has relevant qualifications a a good leadership approach to run the home in the best interests of the service users. Regular quality assurance visits are made, records are well kept and in good order, and the health, safety and welfare of service users is promoted and protected. Evidence: The Manager had been in post for just 6 months prior to this inspection, and his registration with the Commission was in progress. He is well qualified for the post, having a Degree in Economics, a post-graduate Diploma in Health & Social Care, NVQ Level 4 and the Registered Managers Award, and being a member of the Institute of Leadership & Management. He facilitated the inspection well, even though it was a particularly busy day for him. His ethos is to empower staff and be approachable, and he initially pursuing this by carrying out one-to-one sessions and encouraging staff to update their training He demonstrated a strong commitment to providing high quality care to service users and had a thorough and sensitive understanding of their needs. The Registered Provider has used the external PIQASSO quality assurance system for small homes to determine the quality of its services. It also carried out its monthly Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: regulation 26 reports, which are stored on computer and are thorough. Service users cannot participate meaningfully in a conventional service user survey due to their limited cognitive and communication abilities but as stated previously, staff try to determine service users satisfaction or dissatisfaction by interpreting their behaviours and any sounds, gestures or facial expressions that they make. A range of health and safety documentation was seen and was found to be up to date and in good order. This included the certificates and maintenance records for gas safety, fire warning system, fire fighting equipment, water tank (legionellosis), portable appliances, fire risk assessment, hazards risk assessment, fire alarm tests, COSHH risk assessment, lift service, water safe service agreement, fire alarm call points, fire drills, fir risk assessments for each service user, and fire safety awareness monitoring. It is recommended that the actual time of fire drills is added to the fire drill records. See Recommendation 2. Care Homes for Adults (18-65 years) Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 5 5(1b&c) An up to date contract must 31/01/2008 be provided for each service user so that they or their representative are given full information about the service that is being arranged. 2 9 13(4b)(5) Risk assessments concerning 25/10/2007 moving and handling practices must be up to date. This is to ensure that staff have clear guidance on what action to take to support people?s mobility needs and minimise the risk of injury or harm. Immediate requirement issued on 23/10/07 and complied with within given timescale. 3 33 18(1a) Given the age of some 31/03/2008 service users and their associated health conditions and changing needs, staffing levels need to be kept under close review to ensure that their needs will continue to be met. 4 34 17(2) The required records must be 31/12/2007 Page 25 of 29 Care Homes for Adults (18-65 years) 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 kept in the home to show that the employer has undertaken all appropriate checks and vetted its staff correctly. 5 35 18(1)(c)19(5d To further evidence that staff 31/12/2007 ) are adequately trained, each staff member needs an individual training and development profile and certificates of training must be kept on personal files. 6 39 26(5a & b) Southside Partnership must 31/12/2007 ensure that visits are carried out monthly and reports are sent to the Commission. This will further show that the organisation monitors progress within the home and identifies areas for improvement. 7 41 37 The Commission must be 30/11/2007 notified more promptly of all significant events that affect the service users? well being. The manager must ensure that all staff are familiar with the reporting of incidents and accidents under Regulation 37 of the Care Standards Act. 8 42 13(4)15(1) Risk assessments concerning 31/12/2007 Care Homes for Adults (18-65 years) Page 26 of 29 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 Sch.3 (3 q) the premises and safe working practices must be carried out and regularly reviewed. This will show that all hazards have been identified and wherever possible minimised to ensure the safety and well being of all those living and working in the home. Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 Risk assessments should be checked to ensure that those no longer relevant are removed from files and all those remaining have been reviewed as appropriate. This will ensure that all risk assessments on file are relevant and up to date. Staff should ensure that the actual time that fire drills take place is recorded. This will enable the time of drills to be varied to include different times and circumstances. 2 42 Care Homes for Adults (18-65 years) Page 28 of 29 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 29 of 29 - 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!