Care Home: Churchvale Rehabilitation & Recovery Centre

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• The Lodge Nursing Home
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• Church Terrace Nursing & Residential Home
• The Forbury

What the care home does well Churchvale provides a good rehabilitation service with excellent opportunities for people living in the home to develop new skills for when they return back into the wider community. The home has a committed, motivated and supportive workforce whose focus is empowering and supporting the people in their care to meet their goals. People living at the home told us: "(I) really like it here", "staff do really care here", "Everyone has complimented me on how well I am doing and that makes me feel well", People living in the home are empowered to express their views about the home and are listened to by staff. What has improved since the last inspection? Areas of the home have been refurished and redecorated, making them homely and pleasant. Medication auditing has improved so the home is able to demonstrate safe administration and practice is occuring, protecting the well being of people living in the home. Care planning documentation has improved so that staff at the home can demonstrate risks have been assessed and people needs are being met. What the care home could do better: Review intranet access for people living at the home, so they enjoy the benefits of the worldwide web and maintain contact with family and friends via e-mail. Handwritten Medication Administration charts should contain two signatures so that the home can demonstrate which two members of staff have checked the medication into the home. All records pertaining to the running of the home should be available for inspection such as the orginal Criminal Record Bureau check, unless permission has been granted by the Commission. This will ensure the home complies with the legislation and the Commission can valid a robust recruitment process has occured. Key inspection report Care homes for adults (18-65 years) Name: Address: Churchvale Rehabilitation & Recovery Centre Lowry Close Smethwick West Midlands B67 7QT     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: Karen Thompson     Date: 1 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: Churchvale Rehabilitation & Recovery Centre Lowry Close Smethwick West Midlands B67 7QT 01216126720 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Sandwell Mental Health and Social Care NHS Foundation Trust care home 13 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 13 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia (MD) 13 Date of last inspection Brief description of the care home Churchvale is registered to provide 24 hour residential care for 13 people aged between 18 and 65 who are experiencing mental ill health. The focus of the service is to provide intensive rehabilitation to enable people to live independently in the community. The home is situated close to Smethwick town and has good access to public transport networks. Accommodation is provided over two floors accessible via stairs or passenger lift. All bedrooms have en-suite shower and toilet facilities with communal bathrooms available if preferred. There are also many lounge and kitchen areas around the home, a meeting room and laundry. Ample parking facilities are Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 13 Brief description of the care home provided at the front of the building and there is a large garden at the rear. Visitors can contact individuals via the intercom system installed in the main entrance. There is also a pay phone where private calls can be made. The home is staffed by nurses and support staff that are supervised by a registered manager and deputy. The registered manager is responsible to senior managers within Sandwell Mental Health NHS & Social Care Trust All the fees for staying at Churchvale are met by the Health Authority with no cost to people living at 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: The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet peoples needs and focuses on aspects of service provision that need further development. The last key inspection was undertaken on 18 July 2007 when it was given a two star rating. In between this key and the last key inspection we carried out an Annual Service Review of the home. This is where we gather evidence from a number of sources but do not actually visit the home and write a report which is available to the public. Prior to this key inspection visit we gathered information from a range of sources to plan the inspection, which included notifications received from the home or other agencies and an Annual Quality Assurance Assessment (AQAA). This is a questionaire Care Homes for Adults (18-65 years) Page 6 of 29 that was completed by the manager and it gives us information about the home, staff, people who live there, any developements since the last inspection and their plans for the future. One inspector undertook the visit to the home which lasted one day. The manager was present for the majority of the inspection visit. The home did not know that we were visiting. At the time of the inspection eleven people were living in the home. Information was gathered by speaking to and observing people who lived at the home. Three people were case tracked and this involves discovering their experiences of living at the home by meeting and observing the care they received, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and training records were also examined. 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. People have the information they needed to make an informed choice as to whether the home meets their needs. Peoples needs are assessed before they move in, so they can be confident their needs will be met upon moving into the home. Evidence: The home provides a detailed Statement of Purpose that is specific to the individual home, and the service it provides with the objectives and philosophy of the service set out. The guide details what the prospective individual can expect, assisted by supporting documentation that is given to the prospective person at the point of admission in the form of an agreement between the home and the person. The homes Statement of Purpose details specialist services provided, quality of the accomodation, qualifications and experience of staff and how to make a complaint in addition to numerous contact numbers of agencies that will offer prospective persons support. This information about the home is available to all prospective persons wishing to live at the home and time is taken by staff to explain this verbally. People living in the home spoken to confirmed they had received sufficient information Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: to be able to make a decision as to their admission to the home. People are invited to visit the home and are offered an overnight stay if they would like to consider moving into the home. The home specialises in the rehabiliation of people experiencing mental health conditions. The first four weeks of living in the home are considered a trial period where the person moving into the home can decide whether they would like to remain and staff carry out various assessments to ascertain whether they can meet the persons needs. People moving into the home are assigned a named nurse who is available to assist them with any queries or to provide them with support during the admission process. 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. People living at the home are fully involved in decisions about their lives and play an active role in planning the care and support they recieve with the support of staff. Evidence: Discussions with people living at the home confirmed that they were involved in the planning of their care in respect of their lifestyle and quality of life. Care plans were seen to be signed by people living at the home and those spoken to confirmed that they were aware of and agreed with the contents. The staff spoken to underlined the importance of people being supported to take control of their own lives, this fitting in with the homes ethos in respect of rehabilitation of people. The care plans are detailed, focusing on all aspects of well being. People living at the home were being empowered to make decisions about their lives with the assistance of staff if needed. The home has a named nurse system that allows staff to work on a one to one basis and contribute to the care plan with the individual, although this does not preclude people living at the home seeking one to one support from other Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: members of staff. People living at the home had a comprehensive plan of care which was reviewed on a regular basis with input from people receiving the care. There was also involvement of the psychriatrist retained at the service, in order to ensure that the strategies adopted were appropriate for the needs of the individual. All plans contained clear goals that people living at the home had set themselves with the support from staff, thus focusing on how they would develop their skills and consider their future aspirations. Risk assessments were completed in a number of areas. Risk assessments are completed in order to determine any areas of risk in respect of health and to promote independence so that people live a meaningful life, and risks are reduced if needs be and well being is promoted. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are able to make choices about their lifestyle and are supported to develop their life skills in preparation for independent living. Social, educational, cultural and recereational activities meet peoples expectations. Evidence: The home main aim is the rehabilitation of people within the service and the staff actively encourage and provide imaginative and varied opportunities for people living in the home to develop and maintain social, emotional, communication and independent living skills where possible. People living at the home are set goals through the care planning process and they are supported to maintain existing links within the community if they wish to and develop new ones outside the home. People living in the home were observed freely going out into the community to do shopping. People living at the home told us of the range of activities they were involved in such as visiting the gym, attending college and doing volunteer work. Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: The home has its own activity room which contains a pool table and a wishing tree. The Wishing Tree is one form of communication used by people living in the home, including staff. Wishes in the form of notes are placed on the tree and ranged from welcoming someone to the home to something that people living in the home would like. There is a notice board which is filled with information on leisure centres, colleges and so forth. There are televisions in the lounges around the home. People living in the home informed us that the television on the ground floor had freeview which increased the number of programmes they could look at. People living in the home expressed a wish for a computer in the home to allow them access to the intrenet, something they were use to having in their own home. The home has a budget for social activities and people living in the home make suggestions as to how this is used. Activities for people living at the home are planned on an individual basis and also include group activities. One of the group activities is a weekly evening meal for all people living in the home. People spoken to were supported by staff in respect of training to develop employment skills. Some people living at the home had attended college or were working as volunteers in the community. Visitors may call at any reasonable time or with prior agreement and can be seen where the person living in the home prefers, either in one of the many lounge areas, meeting room or bedrooms. The intercom system allows the individual to be contacted directly by their visitors. People living in the home have their own keys to their rooms and were observed using their keys throughout the inspection. Staff were observed to enter peoples bedroms only when invited to do so by the person concerned. Any tasks, which people living in the home are expected to perform around the home are stated in the Service Users Guide as are any rules ( with regards to smoking, alcholol and drugs). People living in the home have unrestricted access to communal areas of the home. People living in the home are responsible for their own meals including shopping, preparing and cooking and as such are able to select their own choice of meals. Assistance and supervision is provided with preparing meals by staff, which is part of the rehabilitation programme of attaining sustainable life skills. Food is kept in individual identified storage facilities in the main kitchen area. In addition to the Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: kitchenette areas the home has a training kitchen that is adapted for use by wheelchair users. People living at the home told us: can cook my food and actually learnt to cook more here. Care Homes for Adults (18-65 years) Page 16 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 people recieve is based on their individual needs, they are assisted to meet these needs by a motivated and supportive workforce. Evidence: People living at the home have two care plan documents. These are split for easy access and retrival of information. The one set of care planning documents contains information for meeting of the day to day needs and the other contains relevant but specific information needed on an has and when basis. Peoples mental health needs are clearly recorded in the care plans with additional information in respect of any relevant health needs. People living at the home have a care plan, which outlines their needs and the actions required to meet these needs. Each person case tracked had their own care plan. The care planning documentation was being reviewed regularly and was found to reflect the rehabilitaion programme for individuals living in the home. There was also a range of risk assessments that highlighted potential risks and the action required to minimise them. All the risk assessments we saw had been regularly Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: updated and amended to show the changing needs of people living in the home. People living at the home are supported by a named nurse system that means they are allocated a member of staff to assist them with any queries, with the staff member advocating for the persons living at the home. This system of support does not prevent people living at the home for seeking support from other members of staff. We spoke to one health care professional after the inspection about the home. They stated it is a lovely place for our clients, staff are very friendly, really approachable, very understanding and supportive of our clients. Personal care is given if needed but independence is promoted as part of the rehabilitation ethos. People living at the home spoke positively about support given to them by staff. All people living in the hme are registered with a G.P. People living in the home all have a lockable facility in their bedrooms to keep their medication in. People living in the home are assisted (if that is their wish) to be in charge of their own medication. There is a three stage process to promote self medication as part of the rehabilation programme. Robust assessment documentation was seen in individual case files to accompany this and there was on going monitoring by the staff that was recorded. Since the previous inspection the policy and procedure for medicaton adminstration has been reviewed and meets the standard. Staff record medication coming into the home on a handwritten medication administration record (MAR). Only one member of staff signs to say they have checked the medication into the home where it is recommended that two staff members check the medication in and they both sign the MAR chart to demonstrate that this has occured. People living at the home collect their own prescription from the G.P and take this to the Chemist. Only trained nurses assist with medication. Care Homes for Adults (18-65 years) Page 18 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. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. Evidence: The home has a detailed complaints procedure and all people living in the home have a copy of this, which is in the Service Users Guide, with additional information available on display within the home. Copies of the resident meetings were shown to us and it was evident that these meetings are used to inform and empower people living in the home to raise concerns which are dealt with by staff. People spoken to at the time of the inspection were aware of the complaints procedure. The home has a robust Adult protection policy and procedure and also has a copy of the Sandwell Social Services procedure. Staff spoken to demonstrated a good knowledge of safeguarding and what to do if they had concerns and how this would be dealt with. Some staff working at the home have also received training in prevention of theraputic strategies. This training gives staff the skills to deal with behaviour that challenges in a none confrontation manner. Whistleblowing, staff have received training in this topic and were aware of their rights and responsibilities in relation to this. Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: In the last twelve months the home has received two complaints which have been investigated appropriately and one compliment. There have been no safeguarding issues at the home in the last 12 months. This is judged to be a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. Care Homes for Adults (18-65 years) Page 20 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. People live in a safe, well maintained, clean and comfortable environment which meets their needs . Evidence: The premises were found to be bright, airy and comfortable. There were various images around the home that promoted positive cultural identity. The home is located within walking distance of Smethwick town centre. There is a vertical lift and good access for all people to the communal areas of the home. There are numerous lounge areas, including activity room, which enables people to have a choice about TV programmes, music or whether they simply want a quiet area. To the rear of the property there is a large garden with pond. People living in the home have their own single rooms, with an en suite shower and wash hand basin (although separate bathrooms were seen to be available for those that preferred a bath). One person showed us their room and we looked at a vacant room, which seemed to be comfortable and well furnished. People are responsible for keeping their own rooms clean. All bedrooms are fitted with a lock with an override device, which can be used in an emergency and people have their own key. The main kitchen has been adapted for people who use wheelchairs. Discussions with Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: the management team acknowledged that adaptations for specific needs may have to be obtained in the future on an individual basis. People living at the home do their own laundry, with the assistance of staff if needed. The laundry is small and domestic in style. There are systems in place for the control of infection. Supplies of gloves were observed around the home. The environment was found to be clean and free from any unpleasant odours and there were handwashing signs, liquid soap, paper towels and hand scrub available. People spoken to were all happy with their rooms and the accommodation at Churchvale. Care Homes for Adults (18-65 years) Page 22 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. People living at the home are supported by staff in sufficient numbers that are motivated and trained to meet their needs. Criminal Record Bureau checks were not available for inspection so the home could not demonstrate its recruitment process was robust. Evidence: The home was found to be appropriately staffed on the day of the visit. Information as to which staff are on duty is clearly available to people living at the home and visitors. The staff group comprises of staff from a diverse background both in terms of gender and culture. People living at the home told us:staff really care here and staff brillant. Staff spoken to all stated that they were well supported to meet peoples needs. The home was seen to have its own training room which is used as a base for training that takes place in house and there was information available here for staff to refer to. The management team informed us that people living in the home are welcome also to attend the inhouse training sessions. We looked at the training matrix which gave us an overview of what training had occurred. Only three members of staff had received training in the Mental Capacity Act and no-one had received training in the Deprivation of Liberty Safeguards. The Mental Capacity Act is an important piece of legislation Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: which came into force April 2009 and staff must have some awareness of this legislation. A copy of the Department of Health Mental Capacity Act and Deprivation of Liberty easy summary was however available in the home. The home was seen to have a staff induction programme which meets the Skills for Care Standard. Staff files seen show that as well as this the home has its own induction programme which introduces staff to organisation and the home. Recruitment records sampled showed that appropriate recruitment checks had been made to ensure staff were suitable to work with vulnerable adults before they commenced work in the home, so people were protected. The staff files however did not contain copies of the orginal Criminal Records Bureau check (CRB). The home needs to read the Care Quality Commissions, Policy and Guidance for Service Providers and Care Quality Commission Staff available on www.cqc.org.uk. If the home wishes to keep the original copies of CRBs at another location then they must seek written permission from the Commission Care Homes for Adults (18-65 years) Page 24 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 and is run in the best interest of people living there. Evidence: The home continues to be managed well. The manager is supported in her work by a deputy manager. Staff also felt supported to do their job by the management team. Staff spoken to during the inspection were enthusiastic about their job. They felt they worked well together and like working at the home. Staff told us: I love working here always something to do with our service users, all about staff being a team and they are a team here and about helping our service users. They had a good knowledge of the peoples individual needs which ensure their needs are met effectively. People living at the home manage their own money. Meetings between people living in the home and staff take place on a regular basis. Minutes of these meeting were seen and a wide variety of topics are discussed which Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: ensure that people living at the home are provided kept informed and are involved in the running of the home. There is a robust quality assurance system in place. Regular weekly residents meeting take place. A newsletter is composed every three to four times a year and is available to people living in the home. The AQAA (annual quality assurance assessment) was returned to us promptly. The document gave good information about the home, staff, people who live there and the improvements over the past year. It also gave information about the plans and areas of development for the future. The home was seen to have policies and procedures in place in respect of the homes safe working practice and discussion with staff evidenced their awareness fo these and their own personal responsibilities, this including the action to taken if they could not resolve an issue. Care Homes for Adults (18-65 years) Page 26 of 29 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 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 1 33 19 Criminal Record Bureau checks must be available at the home for inspection unless permission has been granted by the Commission to be stored elsewhere. This will demonstrate that a robust recruitment procedure has taken place. 23/10/2009 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 2 14 20 The home should look at providing internet facilities for people living in the home. Handwritten Medication Administration Chart should contain two signatures of staff checking the medication into the home. The home should ensure that staff receive training, commensurate with their position about the Mental Capacity Act and Deprivation of Liberty, so they have the knowledge to support people appropriately. 3 35 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. 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