Care Home: Delos Community Ltd, 7 Poplar Street

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What the care home does well Poplar St is a positive and friendly home.Visitors are always made welcome.Bedrooms viewed were clean and contained personal items.Support plans are developed with people who use the service. People who use the service are fully involved with decisions made about them.People using the service are supported to be as independent as possible.Support workers will assist people in meeting their personal and health care needs.Your privacy will be was respected. What has improved since the last inspection? The provider has met all of the requirements made at the previous inspection.The admissions procedure ensures that the service can meet the needs of people making an application to move into the home. The Statement of Purpose has been revisedAdditional staffing is clearly identified for individuals.Management Reviews are consistently undertaken.Notifications of incidents are now regularly reported.Environmental risks are in place. What the care home could do better: Ensure that all documentation in relation to Health & Safety checks is available at the home at all times. Key inspection report Care homes for adults (18-65 years) Name: Address: Delos Community Ltd, 7 Poplar Street 7 Poplar Street Willowtree House Wellingborough Northants NN8 4PL 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 Roan Date: 2 0 0 4 2 0 1 0 This report is a review of the 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 stars – excellent  2 stars – good  1 star – adequate  0 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. They reflect the things that people have said are important to them: 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 34 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 34 Information about the care home Name of care home: Address: Delos Community Ltd, 7 Poplar Street 7 Poplar Street Willowtree House Wellingborough Northants NN8 4PL 01933222452 01933677881 simonh@delos.org.uk www.delos.org.uk Delos Community Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Manager post vacant Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 10 10 10 10 care home 10 learning disability mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of residents who can be accommodation is 10. The registered person may provide the following categories of service only: Care home only - Code PC To residents of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability Code LD and Code LD(E) Mental disorder excluding learning disability or dementia Code MD and Code MD(E) Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 34 A bit about the care home 7 Poplar Street is situated in a residential area close to the town centre of Wellingborough. The home is also known as Willowtree House and is one of four registered homes within easy walking distance of each other, supported by a Head Office and Day Centre in separate premises. The collective facilities are known as the Delos Community where people using the service are known as members . The home provides personal care and support for up to nine members whose primary care need is due to having a learning disability, but who may also have mental health problems. Care Homes for Adults (18-65 years) Page 5 of 34 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 Care Homes for Adults (18-65 years) Page 6 of 34 How we did our inspection: This is what the inspector did when they were at the care home The Care Quality Commission (CQC) has given this service a quality rating of 2 star. This means the people who use this service experience good quality outcomes. We randomly selected two people who use the service and tracked the care they receive through review of their records, discussion with them, the care staff and observation of care practices. We received a completed an Annual Quality Assurance Assessment (AQAA) from the manager overseeing the service whilst a new manager is appointed. The AQAA is a document required to be completed by the provider for CQC. We also received information from other people who use the service. Care Homes for Adults (18-65 years) Page 7 of 34 The home manager has now moved to another home within the organisation to become their Registered Manager. A new manager has been appointed and will be taking up their post shortly. The environment is being refurbished and the number of bedrooms is to be reduced. The organisation will make an application to the commission as soon as these changes have been completed. The inspection was unannounced and was undertaken during the morning and early afternoon lasting 6 Hours. Care Homes for Adults (18-65 years) Page 8 of 34 People using the service said: I am happy at the home but I would like to look at moving into my own home. The staff are nice and I like my new room. What the care home does well Poplar St is a positive and friendly home. Care Homes for Adults (18-65 years) Page 9 of 34 Visitors are always made welcome. Bedrooms viewed were clean and contained personal items. Support plans are developed with people who use the service. People who use the service are fully involved with decisions made about them. People using the service are supported to be as independent as possible. Care Homes for Adults (18-65 years) Page 10 of 34 Support workers will assist people in meeting their personal and health care needs. Your privacy will be was respected. Care Homes for Adults (18-65 years) Page 11 of 34 What has got better from the last inspection The provider has met all of the requirements made at the previous inspection. The admissions procedure ensures that the service can meet the needs of people making an application to move into the home. The Statement of Purpose has been revised Additional staffing is clearly identified for individuals. Management Reviews are consistently undertaken. Care Homes for Adults (18-65 years) Page 12 of 34 Notifications of incidents are now regularly reported. Environmental risks are in place. What the care home could do better Ensure that all documentation in relation to Health & Safety checks is available at the home at all times. Care Homes for Adults (18-65 years) Page 13 of 34 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Judith Roan Compliance Inspector (Northamptonshire) Care Quality Commission East Midlands Citygate Gallowgate Newcastle upon Tyne NE1 4PA Tel: 03000616161 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 set out 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 14 of 34 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 15 of 34 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 considering the service will have their needs assessed to ensure that the service can meet their needs. Evidence: Good information and a pre-admission assessment ensures that the personal care needs of peoples using the service can be met. In reviewing the care files an assessment of need was undertaken for a new member prior to admission, gaining information about their needs and social history. Staff from the service had visited the individual to gain additional information and to observe how staff supported them in their previous home. key workers are allocated at an early stage of the members assessment, and are fully involved in the assessment process. In discussion with a manager overseeing the service as a new manager is appointed they confirmed that there is a clear admissions procedure in place. The service has changed its focus and is now clear about meeting the needs of people who have complex needs and supporting them to live more independently. Care Homes for Adults (18-65 years) Page 16 of 34 Care Homes for Adults (18-65 years) Page 17 of 34 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 needs of people who use the service are met through an effective support plans. Evidence: We case tracked two people at this inspection and met others to discuss how their individual needs were being met. All people said that they were happy at the home and were settled. Some people indicated that their needs were to be reviewed as part of a process of them becoming more independent. Everyone said that they were supported well and that the support workers respected their right to privacy. The care files viewed contained good information on how support workers were to support the person to meet their needs. Considerable work is taking place to produce support plans in easy read formats and to be person centred. Additional one to one support is in place for people who do use the local day centre facilities and this enables them to make real choices about how they use their time. The files contained a range of risk assessments in support of the plans. These were specific in relation to activities undertaken by people using the service. Support plans are reviewed on a monthly basis and where necessary updated to meet changed needs. Records are kept securely in the Care Homes for Adults (18-65 years) Page 18 of 34 Evidence: records store with authorised access. Support workers spoken with were knowledgeable about the care and support each person required. During the inspection positive work was observed with individuals who demonstrated a professional approach in their work. They all spoke respectively and clearly to the people they were supporting. It was also observed that support staff promoted choice which appeared naturally within their practice. People spoken with during the inspection all confirmed that they had worked with their key worker to produce their support plans. One person was not able to communicate their needs easily but in observation and it was clear that staff had a good understanding of their needs. Family representatives or advocates are used in situations where communication needs make the process more challenging. In discussion with the manager they informed the inspector that there had been a number of changes to staff and that new staff were learning the routines and systems within the home well. Regular house meeting are undertaken where individuals are supported to voice their views and to make informed choices about everyday activities within the home. All house meetings have minutes with appropriate action plans Care Homes for Adults (18-65 years) Page 19 of 34 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 supported to have access to a range of activities of their choice. Evidence: Each person has a programme of daily activities within their support plan. One person spoken to said that they were able do activities of their choice and that they liked going out. It was evident that additional staff had been agreed with the funding authority to meet identified needs. Several people who us the service attend a variety of day opportunities. The day centre managed by Delos is opposite the home and people attend this provision on a daily basis or several times a week. Additional funding for one to one support has enabled people to make real choices about activities. The AQAA confirms our findings at the inspection Care plans cover a wide range of developmental needs for individuals. Service users are supported to access a range of daytime educational and day care opportunities. In one instance a personal tutor has been contracted to provide the appropriate level of educational support.The weekly activities programmes are updated to take account of Care Homes for Adults (18-65 years) Page 20 of 34 Evidence: various events and personal choices. Where needed, service users have a comprehensive visual planner to ensure they have a full and stimulating week. During the period of observation it was noted how individuals were supported with everyday activities around the house to enable them to be included and to take on joint responsibility for their environment and their belongings. Individuals choose daily routines, like going to bed when they choose and listening to music or watching TV in their own rooms. All activities are supported with appropriate risk assessments. People using the service are involved with the weekly shopping at a local supermarket and are also supported with personal banking and shopping. The menu is chosen at house meeting, using picture where necessary to aid people with their choice. If someone does not like the chosen meal they are offered a different choice. Meals are prepared at the house and people at the day service return to have their lunch. Most meals are freshly prepared or they go out for a meal on special occasions. Meals are served in the family style dining room. People were seen to choose what they had for breakfast and there was a relaxed getting up process for people staying at the home during the day. One member was seen to be preparing their lunchtime meal assisted by staff. Individuals are supported to make healthy choices and have a balanced diet, with opportunities to have the occasional not so healthy treat. There is negotiation between individuals so that meal times can be arranged around social activities and needs. The standard of food prepared at the home is good. Relatives and friends are most welcome at the service and staff support individuals to maintain contact. The AQAA confirms this by stating Family and friends are supported and encouraged to visit and keep in contact. Support workers confirmed that there was a good relationship between the service and families. Delos runs a Hearsay group for self advocacy that supports and guides members to voice their views. The manager indicated that development over the next year will be To ensure that all choices and decisions made by service users are documented and that staff can show how they came to the decision. And to look at more detailed individualised communication systems so that service users are enabled and more confident to express their choices, needs and wishes. Care Homes for Adults (18-65 years) Page 21 of 34 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. People using the service have their health care needs met. Evidence: In the case tracking of people using the service we found evidence that they were supported to have regular health care checks. In discussion with people who use the service they confirmed that if they were not well they were supported to see their General Practitioner and that regular health checks were undertaken. One person is supported to meet specific dietary needs. Support workers were knowledgeable about the condition and demonstrated how they met the needs of the member they were supporting. There is good information kept which gives an overview of all medical appointments and check ups on an individual basis. Accident/Incident Records stored in the files of people using the service. The manager holds a combined record of incidents to show patterns and trends that can be analysed. Accident and incidents are in the main notified to the commission to ensure that the service is meeting regulatory requirements. We found evidence that some incidents had not been reported. Managers must ensure that these are sent to the commission. Care Homes for Adults (18-65 years) Page 22 of 34 Evidence: Staff training has been undertaken to ensure that administration of medication practice is improved within the home. The AQAA confirms that minor errors on MAR (Medication Administration Record) charts improved greatly. and that an issue with the supplier of medication has been resolved. Medication records were checked and found to be satisfactory. Staff spoken with, were aware of the importance to administer medication accurately and knew what medication was for through the profiles available within the files. There have only been two medication errors since the last inspection. Each incident was fully investigated and action to taken. The manager must ensure that they continue their vigilance in this area. Medication is kept in a locked room with a controlled drugs cabinet within a locked cabinet. Care Homes for Adults (18-65 years) Page 23 of 34 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 living at the home are protected by care practices and listened to. Evidence: There is a complaints procedure in place with an easy read format displayed on the information board at the home. The manager in the AQAA states that We respond to complaints within 5 days of receipt, unless the nature of the investigation process dictates it takes longer. Our organisational culture is to approach complaints as an opportunity for us to improve our service. Service users, their advocates and other representatives have multiple pathways to enter the complaints process. The complaints process is available in a number of documents and in a number of formats. People using the service said that if they were worried about anything they would speak to a member of staff or the manager. There are members meetings held where everyone is invited to attend and share their views about the home. The home has policies and procedures regarding the Protection of Vulnerable Adults and staff training records evidenced that this training has been provided. Recruitment procedures ensure that there is robust checking of new staff through references and criminal record bureau disclosures. The service has had significant changes to the staff team. The manager has been able to recruit to these vacancies. People using the service say that although sad that people have left, they are getting to know the new staff. Care Homes for Adults (18-65 years) Page 24 of 34 Evidence: The manager states within the AQAA that they have been very proactive in this area All staff receive vulnerable adults training as part of their induction - this is refreshed on a regular basis. The company has a robust whistle blowing policy, and a human resource manager to ensure that it respected. We have a robust policy on verbal and physical aggression to staff or service users. Service users who may regularly present with aggressive behaviours will have a specific behaviour support plan to enable the development of more appropriate responses. A grumbles book is kept for minor issues raised by service users on a day to day basis. We recognise that in supporting people who can be vulnerable and who may also have difficulty in expressing their feelings and fears, that the awareness and vigilance of staff is key to protecting people from harm. Care Homes for Adults (18-65 years) Page 25 of 34 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 home provides a warm family setting with individual space that is clean, safe and hygienic. Evidence: People living at the home said that they were satisfied with their rooms and some showed the inspector their rooms. In observations the bedrooms showed that they were homely and reflected peoples individuality. The rooms contained many person items that suited their lifestyles. In touring the building the manager described how the home was to be changed to meet the needs of the members now living at the home. The AQAA states that We are proposing a major physical redevelopment of the home in the next 12-24 months. The communal areas provide a choice of space where individuals can watch TV or spend time relaxing. Standards of cleanliness and odour control in all areas of the home were good. The manager within the AQAA indicates how people using the service are involved with their environment, seek the views and opinions of service users with regard to any decorative or structural changes and improvements to the home. Care Homes for Adults (18-65 years) Page 26 of 34 Evidence: Service users bedrooms are decorated to their own taste, service users are supported to choose what colour they want and what furnishings they want. Service users clean their bedrooms once a week and are supported by staff to do so. The garden is maintained and provides outdoor space when the weather permits. There are several seating areas where people using the service can relax. The gardens seen had been maintained well since the last visit. Health and safety checks are carried out in accordance with the organisations procedures. Standards of cleanliness and odour control in all areas of the home were good. The storage of cleaning equipment has been resolved and no longer poses an obstacle at the door into the garden. Care Homes for Adults (18-65 years) Page 27 of 34 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 skills and recruitment practices ensure that the needs of people who use the service are supported and that they are protected. Evidence: Delos has a thorough recruitment procedure and files seen confirmed that required employment checks had been undertaken: application form, two references, criminal records bureau disclosures and an interview. The interviews also involve people who use the service. The support worker team have a sound knowledge base about the needs of people that use the service. Through observation during the inspection they showed that they had a range of skills to support individuals and were proactive in developing everyday living skills. Support workers are offered a range of opportunities to train. The AQAA confirms the training undertaken with staff at the home. Staff have a four week planed induction which covers building rapport with service users as well as essential training. All staff are enrolled on National Vocational Qualifications in care at level 2 or 3 within 18 months of joining. All staff complete the Learning Disability Qualification induction and foundation elements. There is a well structured rolling training programme administered by the home managers. Care Homes for Adults (18-65 years) Page 28 of 34 Evidence: Records seen confirmed that support workers have access to a wide range of topics that include Person Centred Planning, a system that identifies the individual needs, of people using the service Lifestyle Planning, Epilepsy, Communication, Risk Assessment, Report Writing, Food Hygiene, First aid, epilepsy, Infection control, medication fire awareness, Mental Health, team building, non violent intervention and more. Training records are kept within individual staff files. New employees have to go through a detailed induction programme, based on the Skills for Care professional model. The service has had significant changes to the staff team. The manager has been able to recruit to these vacancies. The previous manager has now moved to a new development and has successfully become the registered manager for that service within Delos. It should be noted that the manager has achieved significant progress in several areas during their time at Willowtree House. Support workers have access to regular supervision and said that they were well supported by managers. Each support worker receives a 3 and 6 month probation interview. All support workers receive an annual appraisal, and can contribute toward their managers annual appraisal. Team meetings occur at least every six weeks. All support workers use the communication systems within the service to full effect; these include the communication book, diary and telephone. Support workers spoken to had a good knowledge of the needs of people using the service and were committed to providing a good service. Care Homes for Adults (18-65 years) Page 29 of 34 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 service is person centred and effectively managed in the best interest of people who use it. Evidence: The management arrangements in place have effectively run the home in the best interests of people who use the service and the support workers. Since the last inspection the manager has moved onto a new service and been registered with the CQC. There was good feedback from people who use the service and support staff about the role of the managers. The organisation has systems in place to reviews the service through continuous monitoring and annual questionnaires for people that use the service their families and other stakeholders. The AQAA confirms this area of improvement We have a weekly quality monitoring system for essential matters such as medication recordings. We conduct an annual quality feedback of the service users to obtain their feedback. The home has an annual and a longer term development plan. Policies and procedures are reviewed annually, with relevant policies being provided in an accessible format. E.g. complaints procedure. The AQAA was reflective about the future development needs of the service and shows Care Homes for Adults (18-65 years) Page 30 of 34 Evidence: that the management team are proactive. Over the next 12 months their aim is to support people within the service To review all health and safety record keeping systems, revisit members involvement in policy and procedure reviewing, run service user survey quarterly instead of annually and update the service user guide and statement of purpose. The provider has undertaken all health and safety checks required. However not all of the records could be found at the home at the time of the inspection with some being kept with the maintainer. These records must be kept in the home for inspection. The AQAA also confirms the checks undertaken but monitoring needs to be reviewed to review all health and safety record keeping systems. Staff were aware and trained in health and safety within their induction training and updates throughout the year. Delos has robust financial checks of personal monies that require records of receipts, running balances. Monies are checked as part of the management monitoring systems. Care Homes for Adults (18-65 years) Page 31 of 34 Are there any outstanding requirements from the last inspection? Yes  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 Care Homes for Adults (18-65 years) Page 32 of 34 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 Description 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 Description Timescale for action 1 41 17 Health and safety records 28/05/2010 must be available for inspection at all times within the home. This is to ensure that evidence demonstrates that regular checks are being undertaken so that people using the service live in a safe environment. 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 33 of 34 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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