Care Home: Dyscarr Grange Care Home

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What the care home does well Dyscarr Grange operates a lengthy `getting to know you` period where people can visit the home and spend time, including over night stays. People living at the service were observed to be happy and relaxed reflecting compatibility with each other. Care and support plans were seen to be developed fully with each person being atthe centre of this. All areas of need were well documented as well as peoples preferences and choices about how their support is provided. Risk assessments were in place to cover all areas of need and showed evidence of ongoing review to reflect any changes. Staff appeared to be very knowledgable about each person and their preferences and were seen to interact with all the people living at the home in a respectful and caring manner. The manager continually strives to improve the service and has introduced a number of communication aids to enable people who experience difficulty in this area, to participate in their care planning and support as well as communicate any problems they may have. The environment is safe, homely, clean and comfortable and provides people with any specialist equipment they require. What has improved since the last inspection? The outcomes for people remain very positive. The last inspection recorded "Annual healthcare checks should include well woman and well man issues." This has now been fully implemented and each person has a health action plan which has been produced in a format to reflect thepersons ability to understand and participate in this process. All support plans are person centred and demonstrate that staff understand the concept of each person being at the centre of this. What the care home could do better: The manager and staff continue to develop and improve the service that is provided for people living at Dyscarr Grange. This is a process which identifies that there is always scope to do things better and provide people with the best service possible. Key inspection report Care homes for adults (18-65 years) Name: Address: Dyscarr Grange Care Home Doncaster Road Langold Nottingham S81 9RJ The quality rating for this care home is: three star excellent 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: Angela Starr Date: 2 9 0 5 2 0 0 9 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 31 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 31 Information about the care home Name of care home: Address: Dyscarr Grange Care Home Doncaster Road Langold Nottingham S81 9RJ 01909540607 F/P01909540607 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : www.mencap.org.uk Royal Mencap Society care home 7 Number of places (if applicable): Under 65 Over 65 7 0 learning disability Additional conditions: The maximum number of service users who can be accommodated is 7. The registered persons may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission are within the following category Learning disability - code LD. Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 31 A bit about the care home Dyscarr Grange is a residential home registered for seven places, for people who have a learning disability. It has a village location, being situated on the main road through Langold, and very close to local shops, chemists, and the Doctors surgery. Langold lies approximately five miles north of Worksop town centre, and is situated on a main bus route. The home is managed by Mencap Homes Foundation, and the property is owned by New Era Housing Association. Dyscarr Grange is well equipped to meet the needs of residents who have an additional physical disability, and there is a passenger lift as well as stairs to access the upper floor. Fees are assessed on an individual basis and are currently within the range of 353 .43. to 602.01 per week. Residents have to self-fund for hairdressing, holidays, meals out, transport costs etc. Care Homes for Adults (18-65 years) Page 5 of 31 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: three star excellent 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 31 How we did our inspection: This is what the inspector did when they were at the care home The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people who use the services and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. We ask managers to fill in a questionnaire called an Annual Quality Assurance Assessment, which tells us how well their service provides for the people who use it and how they intend to improve their service. We received this back from the manager within the required timescale and we used the information it provided us with to assist in planning our visit and deciding what areas to look at. We also reviewed all the information we have received about the service since we last visited in July 2006 and we considered this in planning the visit and deciding what areas to look at. The main method of inspection we use is called case tracking which involves us selecting a number of people who use the service and looking at the quality of the care they receive by speaking with them, Care Homes for Adults (18-65 years) Page 7 of 31 observation, reading records and asking staff about their needs. We also sent Have your say surveys to a random selection of people who use the service, some relatives and some staff members. The information provided in the replies we received was also a contributory factor in the focus of our inspection visit. We spoke with three staff on duty, the manager and two people who use the service to form an opinion about the quality of the service being provided. We also read documents, and medication was inspected to form an opinion about the health and safety of people who use the service. A copy of the latest inspection report can be found by visiting the Care Quality Commission web site at www.cqc.org.uk What the care home does well Dyscarr Grange operates a lengthy getting to know you period where people can visit the home and spend time, including over night stays. People living at the service were observed to be happy and relaxed reflecting compatibility with each other. Care and support plans were seen to be developed fully with each person being at Care Homes for Adults (18-65 years) Page 8 of 31 the centre of this. All areas of need were well documented as well as peoples preferences and choices about how their support is provided. Risk assessments were in place to cover all areas of need and showed evidence of ongoing review to reflect any changes. Staff appeared to be very knowledgable about each person and their preferences and were seen to interact with all the people living at the home in a respectful and caring manner. The manager continually strives to improve the service and has introduced a number of communication aids to enable people who experience difficulty in this area, to participate in their care planning and support as well as communicate any problems they may have. The environment is safe, homely, clean and comfortable and provides people with any specialist equipment they require. What has got better from the last inspection The outcomes for people remain very positive. The last inspection recorded Annual healthcare checks should include well woman and well man issues. This has now been fully implemented and each person has a health action plan which has been produced in a format to reflect the Care Homes for Adults (18-65 years) Page 9 of 31 persons ability to understand and participate in this process. All support plans are person centred and demonstrate that staff understand the concept of each person being at the centre of this. What the care home could do better 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 Angela Starr Care Homes for Adults (18-65 years) Page 10 of 31 CPC1 Capital Park Fulbourn Cambridge Cambridgeshire CB21 5XE 01223771300 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 11 of 31 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 12 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may wish to use the service have the information needed to choose a home that will meet their needs. Evidence: The written information provided for us by the manager tells us We place great importance on supporting people and their families in making an informed choice about where and how they live. Our statement of purpose and service user guide are available for people to see and the admissions policy is adhered to. All people considering moving to the service have a community care assessment in place completed by the local authority. This information also tells us that anyone wishing to consider living at Dyscarr Grange is welcome to visit at any time and spend time with the staff and the other people who live there. We saw the statement of purpose and service user guide and these were comprehensive and very specific to the people who may wish to live at the service. They consider the different styles of accommodation, support, treatment, philosophies and specialist Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: services required to meet the needs of people who use the service. We looked at the methods staff use to make the information they give to people meaningful and interesting. This includes extensive use of photographs as well as leaflets and people already living at the service contribute to this process in a variety of ways, including talking to people about their experience. As part of our case tracking process we looked at files for three people who live at the service. These all contained a comprehensive and person centred needs assessment completed by the manager, in addition to the assessment provided by the Local Authority making the placement. Each persons needs were carefully considered along with the capacity of the service to meet those needs before the placement was agreed. People we spoke with told us that they were very happy with the choice of home. Care Homes for Adults (18-65 years) Page 14 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are involved in decisions about their lives and play an active role in planning the support and care they receive. Evidence: The written information we received from the manager tells us people are supported to lead in the development of their support plans and individual meetings and reviews take place on a regular basis. Relevant risk assessments are in place for each person and these are reviewed on a regular basis as well. Support plans are person centred and address all aspects of the persons life. We case tracked three people who use the service and their files contained thorough and detailed support plans which were clearly developed in conjunction with the person they related to and/or family members and representatives. Information was included about all the additional services and support required and additional plans had been developed to assist staff providing care at the Day Centres. All the files we looked at had risk assessments in place to address a variety of areas of Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: identified risk. These were up to date and the evidence we saw tells us that they are continually reviewed to reflect any changes. The reviews were thorough and addressed all areas of risk. They were signed and agreed by the person where possible or on behalf of the person. The files showed us that people are involved throughout the development of support plans, risk assessments and reviews. People we spoke with told us that they know where their support plans are kept. Care Homes for Adults (18-65 years) Page 16 of 31 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 able to make choices about their lifestyle and are supported to develop life skills. Social, educational, cultural and recreational activities meet individuals expectations. Evidence: The written information provided to us by the manager tells us People are supported to actively engage with and participate in their local community and to develop lifestyles that enable them to reach their goals. There is a families charter in place which encourages and guides staff in supporting people to maintain and strengthen family connections that are important to them. A varied and healthy diet is provided and people are enabled to make choices. We sent out questionnaires to a random selection of people who live at the service and we received four that had been completed. These told us that people do have good relationships with family members and access their local community to participate in activities. Food is good and people make choices about their diet and activities that they Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: pursue. The three files we looked at all had plans in place to support people in a wide range of activities taking place within the local community and at the service. These include attending a Day Centre where they participate in a variety of activities to suit their needs and preferences. Records of activities that take place at the service show us that people participate in outings, holidays, craft sessions, games and some people assist staff with meal planning and preparation. Where communication is difficult, people are enabled to take part in preparing shopping lists and planning meals by using pictures to identify their preferences and choices. On the day of the inspection we observed some people going out with staff, one person was baking and other people were occupied in the lounge area, watching television, looking at magazines and interacting with staff. People we spoke with told us I like to cook and make jelly Im going on holiday soon. I like shopping. One person used their picture board to show us what they liked to do. There is a large, landscaped garden at the home where people enjoy taking exercise, relaxing or having a Barbecue if the weather is nice. One person said I like being outside. The gardens nice. Care Homes for Adults (18-65 years) Page 18 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support in the way they prefer and require. Their physical and emotional needs are well met and they are protected by policies and procedures relating to medication. Evidence: The written information provided to us by the manager tells us Mencaps policy is to tailor the support provided around the individual needs and wishes of the people we support. We focus on each person and agree how their needs will be met. Person centred planning is used to achieve this. This also enables staff to make people more aware of their health needs and feeling good about themselves. We observed that peoples privacy is promoted and supported by the policies and procedures which inform care practice. Staff knocked on peoples doors before entering and offered support in a way which showed respect for the persons dignity and enabled people to take the lead in any support offered. Three files were looked at and these contained detailed and well documented information relating to the support and health care needs of the person. Each plan had been developed using a person centred approach and included a circle of Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: support where the person had identified who the key people are in their life. Photographs supported this information to enable people to recognise their Doctors, Nurses etc. All the people living at the service have been assessed to see if it would be safe and appropriate for them to manage their own medication, however none of the people currently living at the service are able to manage this safely. Medication administration records we saw were all completed correctly and signed. We observed people having their medication and this was carried out in a discreet manner and was explained to the person at the time. Peoples files contained photographs of any medications they were prescribed and these could be used by the person to identify what they were being given. Care Homes for Adults (18-65 years) Page 20 of 31 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 excellent 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 and effective complaints procedure. People are protected from abuse. Evidence: The written information provided to us by the manager tells us People are encouraged and supported to raise any concerns they may have about the service they receive or anything that could threaten their health or well-being. Staff actively engage with the local vulnerable adults processes and ensure that any threat to people is identified and reported promptly and appropriately. People are enabled to comment or complain about any aspect of their lives. We saw the complaints procedure prominently displayed and it was in a suitable format for people who may use the service. The completed questionnaires we received from some relatives told us that they do know who to complain to and that they would feel confident in doing so. One person said they would find it useful to have the telephone number of the area manager to enable them to direct any concerns straight to them. Some people living at the service would be able to make a complaint and told us that they would tell the staff if they were worried about anything. However, there are a number of people who would not be able to communicate any concerns or issues and they rely totally on relatives to advocate on their behalf and on the staff to deliver a good Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: and safe level of support at all times. We saw communication aids that have been developed by the service which enable some people to indicate when things are wrong for them. These include a picture board displaying pictures that represent each persons likes and dislikes. Staff we spoke with understood the importance of taking peoples views seriously and listening to and responding to issues raised. Staff files we saw showed us that staff have attended training in Safeguarding Adults and the minutes of staff meetings told us that the subject is discussed regularly. Staff we spoke with were very clear about their role and the procedures involved. We examined the financial records for the people we case tracked and these were well maintained with clear recordings and signatures relating to all transactions. Care Homes for Adults (18-65 years) Page 22 of 31 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 excellent 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 homely, comfortable, clean and safe environment which meets their needs. Evidence: We underook a partial tour of the home where we looked at the communal areas, bathrooms and some bedrooms. The home benefits from a high standard of decoration and peoples choices are reflected in the colours and schemes they have selected for their bedrooms. A high standard of maintenance and cleanliness is apparant throughout. The equipment provided for people includes a vertical lift, a Parker bath as well as an ordinary bath, walk in shower, hoists and stand aids. The home is furnished throughout with modern and practical furniture that contributes to the overall feeling of comfort and homliness. All areas are well used by people living at the home and each bedroom is decorated and furnished to suit the needs and the choices of the person. Staff we spoke with told us that they have received training in hygiene measures and the control of infection. This was supported by the policies and procedures we saw as well as training records. Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: There is a large lounge area which overlooks the garden and provides people with access to the outside space. On the day of this inspection, people were sitting in this area, relaxing and interacting with staff. A smaller area is provided for people who may wish to have more privacy and is also equipped for people to undertake craft work or other activities. A kitchen/dining area provides a homely space where people sit and talk as well as preparing and eating their meals. The large garden and patio have been landscaped in consultation with people living at Dyscarr Grange and their families. There are raised flower beds, a barbecue area and plenty of space for relaxation. People living at the service told us I love my room. Its just how I want it. I have all my things in my room and I like it to be clean and tidy. Care Homes for Adults (18-65 years) Page 24 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by trained and skilled staff in sufficient numbers to meet their needs. Evidence: The written information provided to us by the manager tells us The services policies and procedures in recruitment and training, guide and inform effective recruitment practices that include thorough pre-employment checks, induction and on-going training to ensure that staff fully understand their responsibilities and how to effectively support people with a learning disability. Staff have regular training and are supported with their continuous professional development. We sent questionnaires to some people who use the service, some staff and some relatives. People who completed these for us tell us that staff treat them properly and respectfully and they like the staff. They also inform us that they feel able to talk about things and have good relationships with the staff. Staff returned questionnaires which tell us they feel supported by the management and have regular supervision and appraisals. Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: Staff we spoke with also confirmed this and added Its a great place to work. We have a really good team and everyone knows that we can rely on each other for support and help when it is needed. We looked at files for three members of staff including the last person to be recruited and found all the necessary information to be present, including copies of two written references, Criminal Record Bureau and Protection of Vulnerable Adults checks. We also saw supervision records and staff we spoke with told us they receive supervision every four to six weeks and find it very useful. They added that they speak to the manager on a daily basis and any problems get sorted out straight away. We looked at the training records and certificates present in staff files and these told us that all mandatory training is up to date and that staff actively seek further training to benefit them in their role. The duty rota showed us that there are always a minimum of two staff on duty but when people are at home as opposed to the day centre, staff numbers are increased to meet the need. Also, when activities are arranged that involve people going out, more staff are on duty. On the day of the inspection the people living at the service were all at home and there were four staff on duty in the morning and a further two arrived mid morning to enable some people to go out. The manager was also present. Care Homes for Adults (18-65 years) Page 26 of 31 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the service is based on openess and respect. There are effective quality assurance systems in place. People living at the service benefit from a well managed and well run home. Evidence: The Annual Quality Assurance Assessment completed for us by the manager tells us The service has clearly defined processes for gaining feedback from people who live at the home and stakeholders. Monthly monitoring visits take place and annual reviews of the service. The manager supports the team and is approachable if they have any concerns. All health and safety checks are carried out weekly to ensure the safety of the people living here and the staff. The completed questionnaires we received tell us that people and staff feel the home is well run and that their health and saftey is protected. The home is currently managed by an acting manager, whilst the registered manager, is on a planned period of absence. Prior to going to this commencing, the manager was very active in keeping the Care Quality Commission informed of any relevant information, Care Homes for Adults (18-65 years) Page 27 of 31 Evidence: including enquiring as to whether there would be any need for the acting manager to register. We looked at the homes system (Quality tree) for gaining feedback from the people living there and saw that all the information gained is used to plan and improve the service. The home operate a continuous improvement policy which enables any problems or concerns that are raised, to be immediately addressed. Residents meet regulary and are empowered and enabled to make suggestions about all aspects of the service, including holidays, activities, decoration and food. All meetings are minuted and pictures added to assist people who may have difficulty understanding. We spoke with the acting manager who demonstrated a great deal of knowledge about the running of the home. People we spoke with told us that they feel it is their home and they make decisions on a day to day basis. Care Homes for Adults (18-65 years) Page 28 of 31 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 29 of 31 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 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 30 of 31 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. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. Care Homes for Adults (18-65 years) Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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