Care Home: Devon House

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What the care home does well The home has an established group of people that have lived in the home for many years. The home as a programme of activities in place that people are undertaking both in the home and in the wider community. The people living in the home are encouraged to maintain relationships which promotes their emotional wellbeing. A number of environmental improvements have been undertaken and the manager plans to make continued improvements. The home was clean on the day of the inspection. This promotes people`s health and well being. All health and safety certificates were found to be in order. This promotes the health and wellbeing of the people living in the home. What has improved since the last inspection? The smoking record in relation to one identified person is being completed and was available at the time of inspection. The fridge and freezer temperatures are now effectively recorded. This will ensure that the health and well being of the people living in the home is promoted and protected. A new health action plan has been developed and the manager is in the process of ensuring that all of the health action plans have been completed. This will ensure that effective recording is in place to ensure that people`s health care needs are being met. Health care appointments are now effectively recorded on the correct documentation. This means it is easier to monitor people`s individual health care needs. A range of training has been undertaken to ensure that staff are better equipped to meet the needs of the people living in the home. The Care Quality Commission is now informed of incidents that adversely affect the well being of people living in the home. This means that professional practice is being followed. What the care home could do better: The manager is in the process of updating the service user guide and Statement of Purpose. The manager needs to develop and update the care plans and identified risk assessments and guidelines to staff in relation to identified behaviours exhibited by people living in the home. Staff training has been booked and staff need to ensure they attend the training to ensure that they can meet the needs of the people living in the home. The maintenance book needs to be completed to ensure that their is evidence that the home is well maintained. Key inspection report Care homes for adults (18-65 years) Name: Address: Devon House 49 Bramley Road Oakwood London N14 4EY     The quality rating for this care home is:   one star adequate 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: Wendy Heal     Date: 0 8 0 3 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 30 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 30 Information about the care home Name of care home: Address: Devon House 49 Bramley Road Oakwood London N14 4EY 02084470642 02088864408 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.craegmoor.co.uk Parkcare Homes Limited Name of registered manager (if applicable) Joseph Clement Mooken Type of registration: Number of places registered: care home 14 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 14. The registered person may provide the following category/ies of service only: Care home only - Code PC. to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia Code DE (maximum number of places:1) (of the following gender: Female). Mental Disorder, excluding learning disability or dementia - Code MD (maximum number of places: 14). Date of last inspection Brief description of the care home Devon House is owned by Parkcare Homes Ltd. Devon House is a large, detached, house in a residential area of Oakwood. There are fourteen single bedrooms. All bedrooms have en-suite facilities and are located on two floors. The kitchen and dining Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 0 1 14 2 5 0 4 2 0 0 9 Brief description of the care home room are at the front of the house. There is adequate communal space for the number of people who live in the home. There is a large garden to the rear of the property. The home aims to ensure people are supported to live as independently as possible. The organisations base fee is £780.00. The home has the Purpose and Function Document and Inspection Report on their notice board for interested parties to view. Care Homes for Adults (18-65 years) Page 5 of 30 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: one star adequate 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 an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards. The inspection process took approximately 9 hours. The manager assisted me throughout the day. I undertook a tour of the home, spoke with people in the home and observed the interaction of people and staff living in the home. Further information was obtained in the home including care plans and health and safety documentation. Care Homes for Adults (18-65 years) Page 6 of 30 What the care home does well: What has improved since the last inspection? What they could do better: The manager is in the process of updating the service user guide and Statement of Purpose. The manager needs to develop and update the care plans and identified risk assessments and guidelines to staff in relation to identified behaviours exhibited by people living in the home. Staff training has been booked and staff need to ensure they attend the training to ensure that they can meet the needs of the people living in the home. The maintenance book needs to be completed to ensure that their is evidence that the home is well maintained. Care Homes for Adults (18-65 years) Page 7 of 30 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 30 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 30 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 who use the service are provided with information they need to make an informed choice about whether the service is suitable for them. At the time of inspection no new people had moved into the home. No new assessments had been undertaken. Evidence: Since the previous inspection there had been no new admissions to the home. The manager is in the process of updating the Statement of Purpose as not all of the information recorded is current. This will ensure that people living in the home are provided with clear information to enable them to decide if the home can meet their individual needs. The people living in the home have signed to say they are happy with the document. Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: The manager of the home is the process of updating the service user guide dated 2008, which uses a pictorial format and is therefore accessible to all of the people who may wish to read the document. Care Homes for Adults (18-65 years) Page 11 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all of the peoples care plans are up to date. They do not all contain current information. People do make decisions about their lives which empowers them. The service must improve with regard to supporting service users to take risks to ensure that peoples needs are met and their wellbeing is safeguarded. Evidence: The care plans were inspected. The care plans are person centred. A discussion took place with the manager and a senior staff member of the team. There were two identified care plans that needed to be updated as some peoples identified needs have changed. The manager and staff members are in the process of ensuring that care plans are updated. All agreed that this was a priority. This will then assist to ensure that peoples individual needs are met. One identified person was case tracked due to concerns identified at a previous inspection. The home had engaged with an independent assessment consultant and the manager confirmed after the inspection that a professional person from the Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: rehabilitation team had attended the home but documents were not available in the home in relation to the outcome of the visit. The homes manager needs to ensure that clear guidelines are recorded in relation to the management of this identified persons specific behaviours in relation to urinating on the floor and other identified shared areas of the home. This identified person is smoking in their bedroom and other identified areas of the home and discards cigarettes in inappropriate places. Clear behaviour guidelines are in place. Guidelines also need to be developed in relation to the management of this persons health care and needs with regard to the management of their personal hygiene and health care appointments. Care plans were informed by risk assessments, the areas covered included depression, medical appointments, smoking in bedrooms physical and verbal outbursts and self -neglect. A number of risk assessments need to be updatedas we saw there had been no evidence they had been reviewed for more than two years. There is evidence that one identified person is still smoking in their bedroom. The flooring has burn marks on it. The kitchen is locked as this person lights cigarettes in the toaster. The evaluations linked to the care plans and risk assessments need to evidence the action taken were concerns are identified which would be highlighted in the behaviour plans. On the day of the inspection the record of room checks that are carried out by staff to remind people that they must not smoke in their rooms were seen and indicated that one identified person was found smoking in their bedroom but refused to vacate to the allocated smoking area but after this action taken was not noted. The records must indicate that effective recording and safety checks with agreed actions are in place. To promote the health and safety of the people living and working in the home. There are a number of minutes from reviews that were not available as they had not been received. The manager needs to obtain these documents and ensure they are on file. This will ensure that the actions agreed at these meetings are available to the staff team who can then ensure that actions agreed at these meetings can be met. Care Homes for Adults (18-65 years) Page 13 of 30 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 part of the community which enriches their lives. Activities are recorded effectively. People are assisted to maintain appropriate relationships. This promotes their emotional well-being. Peoples rights are respected. Evidence: On the day of the inspection the inspector discussed the activity programme with identified service users. A new document in relation to the recording of activities is now being used. Some people do attend centres to undertake activities. Activity records indicated activities such as yoga, attending the walking club, going out to lunch, cinema visits, shopping, undertaking arts and crafts, going swimming at the leisure centre, going to the fun day and disco night. One person has a voluntary job at the church. This assists people to be fully involved in the local community and promotes their self-esteem. People living in the home watch television, and taking part in board games. Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: On the day of the inspection one identified person had been out to the cafe and travelled independently on the bus. One other person had attended a yoga session. People also develop their own life skills by undertaking a number of domestic tasks both independently and with assistance from staff. People living in the home clean their own rooms, carry out their own laundry, assist with cleaning the kitchen, prepare their own lunch independently or with assistance from staff. People living in the home receive visits from the relatives and also go out with their relatives for lunch. This promotes their emotional wellbeing. People have keys to their bedrooms which some of them use to ensure the privacy is respected and some people had locked heir bedroom doors on the day of the inspection. One identified person likes to listen to songs of praise and has their own Bible. However their involvement in activities is limited and requires a great deal of input from staff members for them to engage in an activity. Another identified person attends the church regularly and carries out voluntary work there. This promotes their independence. Devon house does not have a vehicle of its own. All of the people living in the home have a Freedom pass. This assists to further develop their independence and social skills. on the day of the inspection the kitchen was clean and tidy. The fridge for a fridge freezer was inspected and the food was labelled appropriately. Food is being stored within use by dates. This promotes peoples health and well-being. The fridge and freezer temperatures are being effectively recorded. This promotes the health and well-being of people living in the home. The menu of food available is seen. People living in the home are now preparing their own lunchtime meal with assistance. On the day of the inspection one identified person was carrying out the preparation for their meal in the kitchen and dining area and was talking with staff and the other people living in the home. This person confirmed they were pleased with their progress saying I have done well. Care Homes for Adults (18-65 years) Page 15 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples physical health needs are met except for one identified person that refuses to attend health appointments. People do have access to all the necessary health care appointments but these are not being undertaken by all people living in the home. This means that not all health care needs are not being fully monitored. People living in the home are being protected by the homes policies and procedures for dealing with medicines. However one identified document needs a minor change. Evidence: Peoples health care records were inspected. Records indicated that health care appointments are being effectively recorded. Information was evidenced on health care records that indicate peoples health care appointments have been undertaken. However in relation to one identified person that was case tracked as there were concerns identified at the previous inspection their health care needs are not being met. This person is still refusing to attend health care appointments. It needs to be confirmed that this person is able to make decisions in relation to their health care and we recommend a capacity assessment is completed. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: This persons personal hygiene is not good and they have a strip wash occasionally and refuse to change their clothes on a regular basis I was informed about this although there is conflicting information available in relation to this between team members. This does not fully promote this persons health and wellbeing. New health action plan had been developed and the staff within the home are working to develop these further to ensure these are all fully up to date. The medication records were inspected and found to be in order. This ensures that effective recording is taking place to safeguard the wellbeing of the people living in the home in this identified area. The home also has available the sample signatures of staff who are able to administer medication. This document needs to be updated as it was not clear that one identified staff member recorded on the document has now left the home. The medication cupboard was found to be in order. One identified person administers their own medication. There is a risk assessment in place that was signed by the general practioner on the day of the inspection at the request of the inspector. Care Homes for Adults (18-65 years) Page 17 of 30 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 are protected by trained staff. However all of the staff team need to have undertaken training to ensure that all staff have an adequate understanding of how to protect people from abuse neglect and self-harm. Evidence: The complaints book was inspected. They have been five complaints made since the previous inspection. The information had been effectively recorded within agreed timescales and appropriate safeguarding procedures had been followed where necessary. There is a current ongoing safeguarding matter a person has been suspended in accordance with procedures. The complaints procedure was up to date dated 26 May 2009. This document is available in a pictorial easy read format. This assists to ensure that the complaints procedure is accessible to the people that live in the home. The inspector noted that the people living in the home had been provided with a copy of complaints procedure and this had been discussed in this service user meetings. This ensures that people know how to make a complaint if they need to. A copy of the Adult protection Guidance issued by the London Borough of Enfield which is the local authority that the home is situated in was made available to the Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: inspector on the day of the inspection. A copy of the organisations Adult Protection Policy and Procedure was also seen in the home. This ensures that the necessary information is available to staff to ensure that they can protect people from potential abuse. On the day of the inspection the whistle blowing policy was also seen and found to be in order. These documents assist staff to have the required information to report any concerns they may have in relation to the practice that is being undertaken within the home. A number of staff had undertaken adult protection training. However some staff still need to undertake refresher training as training that had been booked had not been attended. This could place people living in the home at risk due to the fact that staff knowledge and skills were not kept up to date. The manager had booked new training dates in relation to this. (Please see staffing Section of the report) the home does not hold the finances of all of the people living in the home. The financial records that are held for those people living in the home were inspected and found to be in order. The home has currently requested confirmation to confirm who is the financial appointee for one identified person. This will further ensure that peoples financial interests are safeguarded. The home have a safe located within the premises which assists to safeguard peoples finances. Care Homes for Adults (18-65 years) Page 19 of 30 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 are living in a clean environment with some environmental improvements are needed. Evidence: Devon house is a detached house located in a residential area in Oakwood. Devon house is located near the local shops and public transport. This assists people to socialise in their community. There are fourteen single bedrooms at the home. Bedrooms have en suite- facilities and are located on two floors. The kitchen and dining room are at the front of the house. There is a large garden to the rear of the property. On the day of the inspection peoples bedrooms were inspected having sought their permission. All of the bedrooms that were inspected were appropriately furnished. Peoples individual bedrooms were personalised with items such as pictures, music centres, televisions and ornaments. This assists people living in the home to feel secure and valued. On the day of the inspection the communal areas including the kitchen were inspected and found to be clean and tidy. This promotes the health and well-being of people Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: living in the home. the kitchen was sufficiently equipped to enable the people living in the home to cook jointly with the staff or cook a meal for themselves independently. This promotes peoples independence. during the inspection the following improvements were noted. The dining room has had the table and chairs replaced. This allows all of the people living in the home to eat a meal together if they wish to. In relation to the lounge there are now additional sofas and a coffee table from one of the other homes within the organisation that has since closed. One identified person has had their bed replaced. This means they can sleep in greater comfort at night. Two identified people have had their bedrooms painted with colours of their choice. The identified person that had a damp area appearing on the bedroom wall has had this problem resolved and there room has been painted. This promotes their health and wellbeing. The extractor fan in the shower room on the top floor of the home has been replaced and the metal pole that the shower head is attached to has been replaced. A discussion took place with the manager with regard to the planned environmental improvements within the home. The manager stated that she wanted to discuss improvements with the people living in the home at the next service user meeting. The inspector has requested that the schedule of planned improvements is forwarded to the Care Quality Commission. on the day of the inspection of a discussion took place in relation to the bathroom seat which currently does not work.The manager confirmed that a request has been made for the bathroom seat to be replaced. The bathroom needs to be painted as the paint is peeling and this does not promote a homely environment. Care Homes for Adults (18-65 years) Page 21 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all staff had completed training in identified areas to ensure they can meet the needs of the people living in the home. People living in the home are protected by the homes recruitment policies and procedures. People are receiving supervision. This needs to be more regular to ensure that a consistent approach by staff can be maintained by the staff in the home. This will promote the quality care provided to the people living in the home. Evidence: The home now has a new manager who was a registered manager in one of the organisations other homes. The manager is in the process of making an application for registration with the Care Quality Commission. The staff rota was inspected and indicated that there were enough staff on shift to meet the needs of the people living in the home. Staff are undertaking a range of training this included health and safety at work and COSHH, manual handling, safeguarding infection control, non-violent crisis Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: intervention, nutrition diet and hydration training, alcohol and drug abuse, diabetes, incontinence care, tissue viability, mental health training, medication training, supervision and appraisal training, fire training, food safety training. The manager had booked staff onto protection of vulnerable adults training and fire training. The inspector was concerned that although training had been booked for staff on a number of occasions they had failed to attend the training provided. A discussion took place with the manager and it has been agreed that identified training needs to be undertaken. This will ensure that staff can undertake their duties in a professional manner. This will ensure that staff have the necessary skills and knowledge to meet the needs of the people living in the home. People are protected by the homes recruitment policies and procedures and all relevant documentation was in place. This included up-to-date CRB checks and two references. This ensures people living in the home are protected from potential abuse. The staff supervision records were inspected and we saw that the current manager is completing supervision in more detail. Care Homes for Adults (18-65 years) Page 23 of 30 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 Quality Assurance system takes into account the views of the people living in the home. This assists with the self-monitoring and development of the people living in the home. Peoples health and safety will only be fully safeguarded when an effective recording system for the maintenance tasks undertaken in the home is in place. Evidence: There is now a new manager running the home who has transferred from one of the other homes within the organisation. The manager is in the process of making an application for registration. The organisation has an established quality assurance system. However the manager informed the inspector that she is in the process of sending out quality assurance forms to service users, relatives and professionals. The compiled report must be kept at the home to indicate that people are being listened to and influencing the running of the home. Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: The Care Quality Commission is being sent regulation 37 notifications of incident forms. This means that professional practice in relation to this specific area is now being followed. A range of health and safety documentation was seen this included the electrical installation certificate, the gas certificate, the records of emergency lighting tests, servicing off the fire alarm, fire-fighting equipment, the portable appliance testing certificate was seen along with the public liability insurance document. This was found to be in order. On the day of the inspection the over-flow pipe from the toilet had been pouring water from this pipe outside the home and down the external wall of the property. This had then turned to ice outside the homes street door over night. This caused the inspector to fall outside the home before entering the premises. The maintenance man was contacted and the problem was resolved on the day of the inspection. The manager informed the inspector that a new maintenance log was being used having inspected this document no entries had been made in this log or the previous book to indicate the latest maintenance tasks had been completed. This does not ensure that peoples health and safety is being fully safeguarded as action taken in relation to maintenance tasks completed is not being effectively recorded. Care Homes for Adults (18-65 years) Page 25 of 30 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 30 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 6 15 The Registered Provider must ensure that all of the information in care plans is accurate and up to date. This will ensure that individual care plans reflect their changing needs. 20/05/2010 2 9 15 The Registered Provider 12/04/2010 must ensure that the risk assessment for the identified person that smokes in their bedroom is updated and linked to the associated guidelines being developed for staff. This will ensure that all identified risks are minimised for the people living and working in the home. 3 19 12 The Registered Provider must ensure that the staff list for the administration of medication is updated. 10/04/2010 Care Homes for Adults (18-65 years) Page 27 of 30 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 This will ensure that a clear record is available with regard to trained staff that can administer medication. 4 23 13 The Registered Provider must ensure that all staff attend protection of vulnerable adults training as training is being booked but not always being attended. This will ensure that staff have been provided with adequate knowledge and skills to protect people from potential abuse. 5 24 23 The Registered Provider must ensure that the bath seat in the identified bathroom is repaired or replaced to ensure that it is working effectively. The bathroom also needs to be painted. This will ensure that the home is maintained to a good standard. 6 35 23 The Registered Provider must ensure that the staff undertake all of the statutory training as required. 10/05/2010 20/04/2010 15/04/2010 Care Homes for Adults (18-65 years) Page 28 of 30 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 The will ensure that all staff have the necessary skills to met peoples individual needs. 7 42 13 The Registered Provider 11/04/2010 must ensure that the maintenance tasks are recorded in the maintenance book. This will ensure that effective recording is in place to evidence the home is well maintained. 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 1 It is recommended that the Statement of Purpose is completed and updated by the manager as soon as possible. This will ensure that clear up to date information is available regarding the home. It is recommended that that the manager completes the updating of the Service User Guide as soon as possible. This will ensure that people moving into the home have clear information to base their decisions on. An assessment under the Mental Capacity Act should be completed in relation to the resident who is refusing to attend health care appointments. 2 5 3 19 Care Homes for Adults (18-65 years) Page 29 of 30 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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