Care Home: Burgess House (Flat A)

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What the care home does well The residents of this home have complex personal, health and social care needs; this service makes sure that they give the specialist support that is required to give their residents the care they need. The organisation provides a good quality training programme for staff to ensure that the staff team have the necessary skills and competency to deliver a good standard of care to this complex and vulnerable group of people in their care. The service ensures that they maintain good relationships with the resident`s families and they do their utmost to support their often difficult relationships. The home endeavours to provide good quality activities and events for the residents tailored to their individual needs and aspirations. The home has good individualised care plans for each resident and understand the importance of the residents and staff are supported by the management team to ensure that they understand the individual resident and their respective needs. What has improved since the last inspection? The home is continually improving and access new activities for their residents. There are now plans in place for the refurbishment of the building relating to the kitchen and bathrooms, the communal areas and some of the bedrooms. What the care home could do better: The organisation is looking a ways to bridge the gap when induction training is not available within six weeks of a new member of staff commencing employment. The manager is endeavouring to get the residents to plan their extra time at the house during the weekend and providing them with information to achieve this goal. Also to ensure that the residents cope with the change from going home at the weekends to spend time in the house in a positive way. Getting information for residents to start planning menus. To plan more holidays with residents. To build good relationships wit parents as they have missed out on information and updates from their sons and daughters in the last twelve months. Key inspection report Care homes for adults (18-65 years) Name: Address: Burgess House (Flat A) 3 Blyth Road Bromley Kent BR1 3RS     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: Susan Meaker     Date: 1 8 0 5 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 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) © 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 29 Information about the care home Name of care home: Address: Burgess House (Flat A) 3 Blyth Road Bromley Kent BR1 3RS 02084600636 02084600597 bromleyautistic.trust@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Bromley Autistic Trust Name of registered manager (if applicable) Mrs Pauline Cremore 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 (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home Burgess House is owned by Kelsey Housing and leased to the Bromley Autistic Trust BAT. The premise comprises four flats with the ground floor flat the home being the registered establishment. The remaining flats are leased to tenants who are provided support through BAT. The home is registered to provide care to four adults between the ages of 18 and 65, with learning disabilities, specifically autism. Bromley Autistic Trust is a local organisation that has a range of services, including three care homes and a day centre, operating within the Bromley area. All referrals and placements are Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 4 Brief description of the care home made through the Bromley Social Services and people using the service attend the day centre located a few doors away. Burgess House is located on a residential road within walking distance of Bromley town centre and its good transport links, as well as excellent shopping facilities. It has four bedrooms, large and small lounge, two bathroomsWCs and a kitchen. There is a large rear garden, which houses a sensory equipment and games. The home is staffed by a Manager and support workers, providing 24-hour care. These staff also provide support to the residents in the remaining three flats. There is access to specialist health services via the Bassetts Centre, which also accommodates the adult learning disability team. Service users access a range of activities through a variety of outlets, including the Trusts day centre and community activities. Placements to the home are made in line with the Service Level Agreement between BAT and Bromley Social Services. The inspector is awaiting information on the current fees. Residents pay privately for newspapers, personal telephone calls, hairdressing, some activities, toiletries and medical services not provided by the NHS. Payment towards transport costs are taken from individual mobility allowances. Information in the form of a Service Users Guide and Statement of Purpose are available for people interested 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: An unannounced site visit was made to this service on the 18th May 2010. BEFORE THE VISIT WE LOOKED AT:- Information received since the last visit. The Annual Quality Assurance Assessment. How the service has dealt with complaints and concerns. Any changes to how th home is run. The providers view of how well they care for people. The views of the people who use the service, relatives, staff and healthcare professionals who visit the service. DURING THE VISIT WE:Talked to the people who use the service, staff, the manager and visitors. Looked a information about the people who use the service and how well their needs are met. Looked at other records that must be kept in the home. Checked that staff had the knowledge, skills and training to met the needs of the Care Homes for Adults (18-65 years) Page 6 of 29 people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last visit. Before the inspection we sent out questionnaires for residents to complete. Care Homes for Adults (18-65 years) Page 7 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 8 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 9 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people who want to use this service and their representatives have the information they need to make an informed decision as to whether the home will suit their assessed personal, health and social care needs. They have their care needs assessed by a person qualified to do so and they receive a contract that clearly tells them about the service they will receive. Evidence: The service has a user friendly prospectus that outlines the services provided by the Trust, in includes a description of Burgess House and the care services offered; the prospectus also details the aims and objectives of the service. People who use the service have a copy and a prospectus has been formulated for the parents of the people resident in the the house. All prospective residents have a full assessment undertaken by the Organisation, which is used in conjunction with the assessment provided by Social services Care Management Team and any other professional assessment. This enables the Home Manager to gather relevant information thereby making the transition process easier for the prospective person who is going to live in the house. The service encourages Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: prospective residents to visit the home. to take part in social activities and sometimes spent the night; before actually moving in, unless it is felt that it would be detrimental to the individual. The last resident who came into the home was asked how he would like his room decorated; his key worker went and obtained samples of wallpaper and paint charts; when he took up residence his room was decorated and furnished to his taste which made the moving in process easier for him. The service has good links with the local Primary Care Trust, Bassetts Centre, where the home is able to access dental, psychiatric and psychological services and the centre also has a speech and language department for referrals from the home. The residents have a service contract outlining the Terms and Conditions of their residency, the fees payable, the service provision and their rights and responsibilities. The home has a Quality Assurance Group, members of this group make unannounced visits to the service; the outcome being that they feedback and make suggestions on how the services offered can be improved. Documentation seen at the site visit relating to, care needs assessment, the service user guide including the contract, care plans, risk assessments, person centred plans and the homes prospectus evidence that the home is compliant with the standards relating to the Choice of Home. Care Homes for Adults (18-65 years) Page 11 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. The people using this service are involved in decisions about their lives, and play an active role in planning the care and support they receive. Evidence: The service ensures that each person resident in the home has a full care plan which includes communication, domestic and personal support needs, a person centred plan and review goals, risk assessments and details of managing challenging behaviour. The service holds six monthly reviews of the person centred plans, the care plans and risk assessments and where possible the residents attend with their family and relevant healthcare professionals. The service has good relationships with the parents of their residents and do their best to ensure that individuals maintain contact with their family and friends; this includes taking residents to their family home when needed and supporting home visits if required. The residents are supported and encouraged by the staff of the home to maintain their life skills by the use of visual display boards, using photographs of events; the staff Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: have also had professional guidance from speech and language therapists on how best to communicate with individual residents and this enables the service to promote choice, wishes and preferences. One of the residents was involved in interviewing new members of staff, in a structured setting being part of the interview panel; this proved to be successful and gave the resident insight into how recruitment and selection was managed by the service. Full risk assessments are undertaken specific to the individual Care Homes for Adults (18-65 years) Page 13 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 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 use this service are able to make choices about their lifestyle, and are encouraged and supported to develop their life skills. Social, educational and recreational activities meet the individuals expectations. Evidence: All residents are supported and encouraged to be as independent as possible. The home has a domestic task rota and each resident has a level of participation relevant to their capability. They have written guidelines for staff so that they can support each resident to undertake these tasks; this also applies to personal care where the residents are encouraged to do as much for themselves as possible, the care plans accurately reflected the assessed personal, health and social care needs of the individual and how these needs were to be met by the staff. Two residents attended an autism specific day service where they take part in programmes for computer, literacy and numeracy skills. Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: Two residents attend weekly keep fit sessions. The staff often take residents into the local town and access amenities such as the shops, pubs and restaurants, and the home had a selection of leaflets identifying activities and events that were taking place in the local area. For the last four years the residents have chosen, after consultation, to go to Butlins for a weeks holiday, the feedback from the residents and from their families suggest that this is a very popular event and that they enjoy this Holiday very much. The home has good links with all the families of the resident and they endeavor to maintain good relationships, often family members attend social events and the home and the staff encourage the residents to go on home visit if appropriate. The residents have access to all communal areas within the home, unless a risk assessments state otherwise; if they prefer to sit apart from the other residents this is possible and a staff member will be on hand if needed. All residents and staff are aware that bedrooms are private and that they must seek permission before entering. As all the residents of the home lack social awareness it is very important that the staff knock on bathroom doors and encourage residents to dress appropriately before going into communal areas. Residents have three meals a day and these are chosen on a Sunday, although the home has a list of individual likes and dislikes as choice in this area can prove to be quite difficult. Mealtimes are very structured, due to the residents autism; they take place at the same time each day, to increase predictability and thereby reduce the individuals anxiety; the home has guidelines in place to help staff in this particular area. The home has monitoring charts, evidence in PCPs of activities undertaken by the residents, feedback from parents and action plans from residents meetings that they support and encourage the residents to participate in activities to maintain and in a lot of instances improve their preferred lifestyle. 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. The health and personal care that the people, who live in this home, receive is based on their individual assessed care needs. The principles of respect, dignity and privacy are put into practice. Evidence: The people who use this service need support and encouragement to undertake personal care, however the individual, if able, can choose which member of the staff team supports them, it was evident from looking at a sample of the care plans that they had detailed instructions relating to how personal care was to be delivered. The residents were supported and encouraged to purchase their own clothing and personal items such as toiletries, DVDs, CDs computer games, magazines, newspapers and books. All the people who use this service respond best to a structured environment and the home has a detailed shift planner that enables activities to be predictable. Currently, none of the residents are able to communicate when they are unwell, as such the staff recognise the importance of reporting changes in the behaviour of the residents. Ok health checks are completed to ensure that all regular checks are undertaken; all Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: residents have regular health and medical check ups and appointments; all residents are registered with the local GP and have access to the Bassetts Centre which specialises in meeting the needs of people with disabilities. Only the staff who have completed the course in the Safe Administration of Medication, and who are assessed as competent, can support residents to take their medication. The home also has policies and procedures, in place relating to the safe use and administration of medication including medication given away from the home. Residents are aware that they are being given medication and what it is for, medication is never given covertly. Policies and procedures relating to the safe storage and disposal of medication is monitored by the homes pharmacist and to date there have been no problems identified. Medication is reviewed by the home manager and their pharmacist and on Regulation 26 visits by the management of the Organisation. The care plans, shift planners, OK health checks, reports of health checks undertaken and advice given, medication stock checks and MARS documentation evidence the support and encouragement given to residents relating to personal care and healthcare support. 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 people who live in the service are able to express their concerns and have access to a robust, effective complaints procedure , and are protected from abuse and have their rights protected. Evidence: The service has a good, clear and robust complaints policy and procedure; the residents and their relatives/representatives have a copy of this document and it is displayed on the homes notice board. There is a complaints book where all complaints and concerns are logged and investigations and outcomes and resolutions are recorded. Due to the level of disabilities of the residents they would not be able to verbalise a complaint; staff are aware of this and record behaviours that might indicate that the resident is unhappy or concerned about a situation or person. Risk assessments are in place to safeguard any resident who may be harmed; all staff are trained in Safeguarding Vulnerable Adults, there was evidence of this training taking place in the staff personal files. The staff are also trained in the strategies of crisis intervention and prevention; each resident has a section in their care plan that outlines what interventions can be implemented. The home has a policy and procedure in place for the use of physical interventions and protection. Residents money is kept in a sealed bag and all spends are accounted for and Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: recorded in individual account books and the home manager undertakes regular audits of money held in the home. The home has a complaints/suggestion box in the communal hallway enabling the residents, their relatives and friends an opportunity to comment on the service. From looking at the complaints records, the financial books for each resident and the Petty cash records it was evident that the service complied with the standards relating to concerns, complaints and protection. Care Homes for Adults (18-65 years) Page 19 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. The physical design and layout of the home enables the people who use the service to live in a safe, well maintained and comfortable environment, which encourages independence. Evidence: Burgess House is situated within walking distance of Bromley Town Centre and has access to a sports centre, theatre, cinema, shops, supermarkets, pubs and restaurants; it is situated within walking distance of a mainline station for services into London and to the Kent coast and seaside resorts; there is also a very good bus service in the area. The house itself is domestic in style, it has been converted to accommodate four residents who have a diagnosis of autism/asperges syndrome, it is situated in a quiet residential street. The house is furnished in a domestic style and has a homely feel, some of the decor, soft furnishings and furniture is looking a bit shabby, particularly in the kitchen and bathrooms; the home manager has implemented a roling refurbishment plan to update and improve the internal appearance of the house. However the bedrooms are well decorated and furnished to the residents personal taste; and there was evidence that the resident had chosen how they wanted their bedroom to look and there were lots of personal items, TV, radio, CD and DVD Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: players, pictures, ornamants and photos. The house has a large garden, mainly lawn where the residents can participate in oudoor activities and events such as ball games and BBQs. Therre is a large summerhouse in the garden where there is a range of sensory equipment in one section, where there is soft seating. In the other section there is a range of games including table football, large air hockey table, magnetic darts plus a range of craft activities. At the time of the site visit the house was clean and tidy and the manager explained that they are following the recommendations given by the safer food better business initative. All the staff have been trained in food hygiene, health and safety anad infection control. The home has been awarded a four star certificate by Environmental Health. From looking at documentation relating to daily planners, fire risk assessment, Gas and Electricity safety certificates, farm alarm testing, recording of food and water temperatures; it was evident that the house complied with the standards relating to the environment of the house. Care Homes for Adults (18-65 years) Page 21 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff who work in the home are trained, skilled and sufficient in numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. Evidence: It was evident, at the site visit and records seen, that the staff of the home are aware of their role and responsibilities; every staff member has signed a declaration to say that they have read and understand the organisations policies and procedures. The staff have good relationships with the residents and are aware of their individual communication needs as identified in their care plan. The home ensures that there is always a member of staff on duty is familiar with the individual communication need of each resident. The organisation has a comprehensive training programme, as seen in the annual training plan, staff undertake mandatory training relating to fire safety, first aid, food hygiene, health and safety, LDQ induction, adult safeguarding and protection and Philosophies of Care, other training courses are also available. The home has a strong, skilled, experienced and competent staff team who deliver good quality care to a group of very vulnerable young adults with a severe and complex disability. The home has a 24 hour on call system and a sleep in senior on duty through the Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: night; there is a designated deputy manager and senior staff who are experienced and to who staff can go to for support and advice. The manager ensures there are regular team meetings and all staff are supervised on a regular basis; there was evidence to show that the manager had undertaken supervision and effective team work training. The Organisation has comprehensive and robust policies and procedures relating to the safe recruitment and selection of staff that are adhered to ensuring that the staff have the right skills and experience to meet the needs of the residents and the service; evidence of these processes being followed were found in the staff files. Staff employed must successfully complete a six month probationary period which is in their contract as part of the Statement of Terms and Conditions. Care Homes for Adults (18-65 years) Page 23 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 management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. Evidence: The manager of the home has worked at all the houses within the Organisation over a period of nine years, he was appointed the manager of Burgess House in 2009, it was evident from watching him interact with the residents during the site visit, that he has a good rapport with the residents and staff of the home; he also demonstrated a good knowledge of his residents needs and aspirations; he has a degree in social science, a teaching qualification and NVQ 3. The current manager has applied to CQC to be the registered manager of the service and is to undertake the RMA as soon as possible. The manager ensures that the staff team are supported to understand and implement the organisations policies and procedures. The organizations committed to equal opportunities, diversity and the protection of human rights. All records are kept in a safe place that complies with the Data Protection Act. Residents and their relatives are surveyed annually to get their views on the service Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: and the aims of the service. The home undertakes six monthly reviews of the residents care plans, risk assessments and PCPs. The organisations Residential Service Manager undertakes regular monthly monitoring visits to comply with Regulation 26. The organisation holds service manager meetings on a monthly basis. It was evident from inspecting Health and Safety records that the home complies with current legislation. The home displayed in the hallway the current Registration Certificate ans a copy of their liability insurance. Care Homes for Adults (18-65 years) Page 25 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 9 13 (4) Risk assessments must be 01/10/2007 specific to ensure the risks are fully identified to ensure staff have the information to protect the individual. Medication records must identify all medications leaving the home. This must include medication whilst on leave. 01/10/2007 2 9 13 (2) 3 23 25 The procedures in relation to 01/12/2007 management of residents monies must be made clearer. In particular, the Provider must address how it apportions residents mobility allowances in accordance with the usage. This is a repeated requirement with the timescale of 01/08/06. 4 24 23 An action plan must be 01/11/2007 provided for the redecoration of the home. Infection control procedures 01/11/2007 must be implemented to ensure the home is clean and infection risks are reduced for those living there. 5 30 13 (3) 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 6 34 17 & 19 Employee references must 01/10/2007 be verified prior to staff being employed to work in the home and the organisation must confirm in writing to the manager that they have completed the required checks to ensure residents are protected. 7 39 24 A review of the service must 01/12/2007 be completed each year to enable the service to continually improve and meet individual expectations. 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 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. © 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. 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