Care Home: Chapel House

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What the care home does well Chapel House is a well managed and well run unit ensuring a good standard of care for the people living there. Clients had access to everything they might need to actively engage in a level of independence that encompasses aspects of self care and minimises `dependence` or `reliance` on others. The unit is clean and safe and the standard of the accommodation is good. There were effective systems for keeping the unit maintained to a good standard. Staff are well trained and show commitment towards giving good care to the clients. Records were kept to a good standard and the office was well organised. The unit is good at seeking the views of clients and involving them in all aspects of their care and rehabilitation. What has improved since the last inspection? This is the first inspection of this service. What the care home could do better: It would be beneficial if there could be details of staff recruitment information on site, for example, the date when the application was returned, when the references were returned, dates when staff commenced work and the CRB disclosure numbers etc. Perhaps the manager could discuss with senior management about setting this up on a spread sheet on the computer. Key inspection report Care homes for adults (18-65 years) Name: Address: Chapel House 1 Newton Road Billinge Wigan Lancashire WN5 7LA     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: Judith Stanley     Date: 1 1 0 2 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: Chapel House 1 Newton Road Billinge Wigan Lancashire WN5 7LA 01942707000 01744638012 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.trurehab.com TRU Limited Name of registered manager (if applicable) Mr Matthew Anthony Unsworth Type of registration: Number of places registered: care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 physical disability Additional conditions: The registered person may provide the following category of service only: Care home only- Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical disability- Code PD The maximum number of people who can be accommodated is: 18 Date of last inspection Brief description of the care home Chapel House is part of the Tranisitional Rehabilitation Unit group (TRU). The unit offers rehabilitaion for people with an Aquired Brain Injury (ABI). The unit is sited in the Billinge area of Wigan and is close to local amenities and public transport. The unit comprises of Stanley Seaton House, The Willows and Chapel House. All the Care Homes for Adults (18-65 years) Page 4 of 28 Over 65 0 18 Brief description of the care home units have single bedrooms, shared bathrooms, kitchens, dining space and lounges. Clients have access to a home cinema room, gym, activity room with a pool table, games consoles and games and a laundry. Outside space with suitable seating, a picnic and barbeque area is available and there is a gazebo which is the designated area for people who wish to smoke. The scale of fees varies depending on the package of care and the services required. Care Homes for Adults (18-65 years) Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was the first inspection of this service since becoming registered in 2009. The inspection was unannounced and included a site visit. The inspection was completed over a six hour period on one day. During the visit we spent time looking at care records as well as information about the staff and health and safety including how the home and the equipment were kept safe. With permission of a client, we attended a review to see how that was conducted, we looked around the premises and spoke with the clients and staff. As part of the inspection process the manager was asked to complete an Annual Quality Assurance Assessment (AQAA). This tells us how the unit focuses on the outcomes for clients, what they feel they do well at and in what areas they can develop and improve. We felt the AQAA was filled in honestly and that a lot of time and effort had been given to complete this form. Care Homes for Adults (18-65 years) Page 6 of 28 To help us gather further information we sent out surveys to clients and staff. We received nine completed surveys from clients and six from staff. Clients indicated they were happy living at the unit and that they had been asked if they wanted to live at Chapel House and that they were given enough information about the unit and the services provided. One said, The staff are good and very approachable. Another said, The accommodation is safe and sound, the staff help us and encourage our rehabilitation, they are always there to answer any questions. Staff comments were positive with regard to recruitment and training . When asked, what they think the unit does well at? One said, It provides effective and supportive rehabilitation to all clients, ensuring that all their individual needs are met. The team are supported in providing a consistent service and they can voice any issues in a safe and private manner. Another said, It adapts to individual clients needs and provides a range of services available to every client. It also provides clients with the tools they need to become more independent following an acquired brain injury. Discussion and feedback was held with the registered manager during the visit. Care Homes for Adults (18-65 years) Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: 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 28 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to assess and monitor individual needs, ensuring that a suitable service is provided bases on personal needs and preferences. Evidence: The unit has a statement of purpose and a service users guide. This informs people about the aims and objectives of the unit for example, the core value of the organisation emphasises that the service users who are victims of acquired brain injury (ABI) have the same rights as any other citizen and that it is the teams intention to maximise potential and independence and minimise disability and dependence on others for the service user. The information tells people about the staffing team, about clients rights, terms and conditions of residency, a list of useful telephone numbers, general information and details of the complaints procedure. Chapel House is a mixed unit for younger adults between the ages of 18 - 65 years of age. The criteria for admission is that the person has a diagnosis of suffering an ABI, however all clients need to be medically stable. Admissions in to Chapel House are usually from another TRU (Transitional Rehabilitation Unit) facility such as Lyme House Care Homes for Adults (18-65 years) Page 10 of 28 Evidence: or Ashton Cross. The manager completes an admission assessment which covers personal details and family contacts, the level of care and support needed, a health medication assessment, a list of medication, religion, martial status, past experiences, hobbies and interests and what vocational activities and groups they be may be interested in. An invite letter is sent to the prospective client to attend an assessment. The client and their supporters are invited to view the vocational areas, these include mechanics, woodwork, computers, arts and craft work etc. Prospective clients are also able to look at the social communal areas, bedrooms and bathrooms and get the opportunity to meet staff and other clients. Every client is provided with a Statement of Terms and Conditions of Residency. Clear and concise points are documented and agreed and these are signed and dated by the client. Care Homes for Adults (18-65 years) Page 11 of 28 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Chapel House are involved with the development of their individual care plans so they receive the care and support they need in the way they prefer. Evidence: We looked at two clients care files. The care files contained very detailed information that had been built up over a period of time. Reports from other professionals and services are included. In the Rehabilitation file there is the Care Pathway General Contents, this includes a status sheet detailing contact details, legal status and background, a Risk Assessment and Management Plan, Activities of Daily Living (ADLs) and an Occupational Therapy Assessment. There is information about medical background, Physiotherapy and the Speech and Language Team involvement and monthly reports etc. As much information as possible is collated about the individual, from family background, previous education and employment, when and how the ABI occurred and how their life has changed. New clients are always asked about their likes and dislikes with regard to vocational opportunities and leisure activities. There is a wide range of vocational and leisure options available including woodwork, Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: mechanics, computers, office duties, reception, gardening, arts and crafts, card craft, fishing and painting and decorating, These are discussed and possible options are highlighted. On arrival at the unit they are shown around the site to familiarise themselves and are shown their room which they are supported to personalise with their own belongings and mementos. Every client is allocated a Primary Coach and a Rehabilitation Programme Coordinator who will work with the client and suggest further goals, these are discussed at weekly meetings and reviews. Where possible clients are encouraged to make choices and decisions. Staff respect clients rights and that right is limited only through the assessment process, involving all parties and this is recorded in the care plan. Files were seen to contain risk assessments relevant to the individual. Risk assessments seen covered falls, absconding from site, self harm, road safety and aggression etc. There is an element of risk at vocational placements with the use of tools, kitchen utensils, and with leisure activities. These are assessed and monitored. Clients are encouraged to keep in contact with family and friends. The staff will coordinate home visits and family visits to the unit. Dates and times of visits to the unit are agreed with the team so not to coincide with reviews and other planned events. Clients are consulted with and participate in aspects of life in the home. Clients are invited to reviews and attend meetings and forums. With the permission of a client the inspector sat in on a review. The client contributed to the review and was given full and clear feedback from the staff team Clients were aware that information about them is kept and handled appropriately. Records were seen to be accurate and all staff concerned sign and agree records in the care file. Records were seen to be securely stored and were confidential. Care Homes for Adults (18-65 years) Page 13 of 28 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are enjoying a good quality of life and are involved with a good range of activities both in the home and the local community. Clients are offered the opportunity for personal development. Evidence: There was evidence to show that clients had the opportunities for personal development. Staff encourage and support clients to learn and develop practical life skills. Clients are offered a range of vocational and external placements. One client showed the inspector a chair he was making in woodwork and was obviously very proud of his work. One client attends the local collage twice a week, another is a classroom assistant and other clients are involved with the Dogs Trust. Staff support clients with leisure activities with trips to the local pub, library, church, shopping, cinema, bowling, snooker hall, theatre, football matches and they have the option to apply to the holiday club to holiday destinations, these have included the USA, South Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: Africa and Venice. Some clients have attended a Life-styles therapy group focusing on sleep, hygiene, nutrition, exercise, smoking, alcohol and drugs. The manager confirmed that clients have consistently attended certain evening and weekend options. With the help of staff, if needed there is an expectation that clients will maintain the cleanliness of their bedrooms and help with other domestic tasks in the unit. As part of their daily living activities, staff help clients plan, shop and cook their own meals. The inspector was shown that in the kitchen every client has their own food cupboard and a section of the fridge and freezer. Clients are supported in making sure that these are kept clean and that stock rotation is maintained. A menu planner for each day of the week is planned to ensure that clients are receiving a healthy and well balanced diet within the weekly shopping budget. The unit offers some group meals such as breakfast and evening dinner. Clients have access to fruit, cereal bars, bread, cereals and hot and cold drinks as required. To ensure clients health and well being, clients have access to monthly health checks with the registered nurse this include monitoring weight and their BMI. Care Homes for Adults (18-65 years) Page 15 of 28 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The promotion of clients health and well being is taken seriously. Peoples welfare is monitored and their health needs are met. Evidence: Clients receive the personal support in a way that suits them. This is discussed with their primary coach. Daily routines are planned for example times and preference when clients wish to bathe, times of getting up and going to bed are agreed. Clients make their own choice about clothes, hairstyle and their general appearance. All clients have access to a local general practitioner, chiropodist and dentist as required. Clients can receive additional, specialised support and advice as needed from the units own professional clinical team which is available seven days a week. The team includes, Clinical Psychologists, Neuro-psychiatrist, Physiotherapists, Speech and Language Therapist, Counsellors etc. Staff at the unit ensure that the health care needs of all clients are assessed and recognised and that procedures are in place to address them. Good systems were in place for the safe storage and administration of medication. Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: Only certain members of staff administer medication and these staff have been suitably trained in doing so. When medication is being administered, two members of staff are present to ensure that medicines have been given properly and that the recordings on the Medical Record Sheet are accurate. The unit has a Medication Officer as part of the training team facilitating training and refresher courses for staff. Currently there are no clients receiving any controlled drugs, however it was discussed that the unit needs a controlled drugs cabinet in the event of a client being prescribed a controlled drug. A list of all clients medication and any possible side effects was seen in the care file. Care Homes for Adults (18-65 years) Page 17 of 28 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good safeguarding procedures help to ensure that clients remain safe at the unit. The complaints procedure is clear and accessible meaning that people who live at the unit feel listened to and are taken seriously. Evidence: There were good systems in place for the recording and monitoring of any complaints. There had been seven complaints made to the unit manager within the last year. These were recorded and the outcomes documented. All staff had completed current and up to date training in the Protection of Vulnerable Adults. The assistant manager is a qualified trainer in this area and delivers training to the staff on all forms of abuse. Staff have been trained to deal with verbal and physical aggression. This can be dealt with in a number of ways. Two of the methods used are Time Out On The Spot (TOOTS) and Reinforce Appropriate And Ignore Destructive (RAID). Staff on occasion have to use physical intervention if a client is putting himself, other clients and staff at risk of harm. The least restrictive practice is used for the least amount of time. All staff have completed training with regard to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLs) Care Homes for Adults (18-65 years) Page 18 of 28 Evidence: Different systems operate with regard to clients monies. Clients have the opportunity to achieve individual targets that are rewarded by therapeutic earnings. These earnings can be exchanged for TRU money or sterling as agreed in the clients weekly budget sheets. TRU money can be exchanged in the TRU shop to purchase items required such as cigarettes, toiletries, sweets etc. Both TRU and sterling money is accounted for and recorded in the clients cashbook. If required, clients money can be securely stored in the units safe. Care Homes for Adults (18-65 years) Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Chapel House provides a safe and comfortable environment that is well maintained and decorated and furnished to a good standard. Evidence: From a tour of the premises and the outside area it was evident that the unit was well maintained and furnished to a good standard. The unit is split in to three separate residential units. Stanley Seaton House offers accommodation for twelve residents. The unit comprises of single bedrooms, with a shared shower room and toilet facilities between two bedrooms, two lounges, two dining rooms and two kitchens split over two floors. The Willows has two individual flats, with their own bedroom, kitchen/diner and bathroom. The Willows is used for assessment of clients in preparation for independent living. The Willows also houses the laundry, the boiler house, the larder, activity centre and the cinema room . Chapel House has four self contained flats, again each has their own bathroom, kitchen/diner, lounge and bedroom. These flats are generally used as a continuation from successful independent living trials. Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: One client showed the inspector his bedroom, this was seen to be clean and tidy and was furnished to a good standard. The room had been personalised with the clients own possessions and mementos. There was a white board on the wall which is an important memory aid for this client which assists him with orientation and tasks that need to be addressed. Each client is provided with a key to their personal living space. The communal areas of the home were well equipped and were comfortable. Clients have access to telephone facilities within the unit or use of their own mobile. It was discussed with the deputy manager about the use of CCTV camera, these are used for outside security, however they are also fitted in the lounge areas. The deputy manager explained that these were necessary in the communal area to allow staff to sometimes assess situations that may occur. The tapes are regularly erased and only viewed when necessary. The grounds have parking at the front of the unit and gardens to the side and rear. There is gazebo, barbecue patio area and and orchard. Suitable seating is available. The premises were clean and hygienic and systems were in place to control the spread of infection. The unit has suitable laundry facilities housed in the Willow unit. Care Homes for Adults (18-65 years) Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The clients living at Chapel House are supported by a well trained and effective staff team. Evidence: The clients at Chapel House are supported by a competent, experienced and qualified team. Staffing levels on the units was good and staff are supported by ancillary staff. Specialised services are secured from relevant professionals to support the assessed needs of the clients. It was discussed with the manager regarding staff recruitment files. These are kept at Margaret House. The unit manager confirmed that following an interview, successful applicants will have their references checked and an enhanced CRB check. It was discussed that a record of these checks would be beneficial on the units computer for easy access and verification. On commencement of work new staff work through a three day checklist which is signed off by the manager. This is followed by a new staff shadowing an experienced member of staff for up to three weeks. The induction period lasts for six months then staff are eligible to attend Primary Coach training classes. Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: Refresher training is offered each month on certain areas that the management team feel need addressing. Staff training includes, team meetings, confidentiality, role modeling, sterling, dress code, prompting, TOOLS, RAID , therapy groups , planner levels etc. Several staff have achieved NVQ level 2 in health and social care and one member of staff has NVQ level 4 in Leadership and Management. Care Homes for Adults (18-65 years) Page 23 of 28 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The unit has an experienced management team who ensures that the unit is operating efficiently and effectively and in the best interests of the clients that live there. The unit is well run and a high level of consultation with clients meant that people living at the unit could contribute to its development. Evidence: The manager ensures that the unit is run in the best interests of the clients and he is well supported by a dedicated and committed staff team. The manager has a thirteen years experience of working with clients with ABI and has worked across all the four TRU sites in different roles before becoming the registered manager of Chapel House in 2009. The manager is committed to his own training and development as that of his staff and is currently working to complete Level 4 in Management. The manager has monthly meetings with the Programme Director and evaluation twice a year to ensure that the unit is being run responsibly, efficiently and competently. Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: Good quality assurance systems were in place, these included surveys given by clients regarding their views on the coaching team and for the services provided at Chapel House, communication with families and external professionals, review of accidents and incidents and achievement of clients treatment and goals. The manager ensures that the health, safety and welfare of client and staff are promoted and protected. Appropriate polices and procedures were in place and easily accessible to staff. Should any accidents and incidents occur, they would be recorded and the CQC are notified as required. Fire risk and management procedures were in place and a recent fire drill had been carried out. Chapel House was registered in 2009 therefore all the equipment and appliances had been tested prior to registration being granted. This includes the gas, electrics, fire detection and alarms, fire fighting equipment, emergency lighting and all portable electrical equipment Care Homes for Adults (18-65 years) Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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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