Care Home: Follybridge House

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What the care home does well The home has a friendly, caring inclusive atmosphere in which the residents feel confident that they are very well cared for and their right to privacy and dignity is upheld at all times; this was clearly evidenced during the inspection. The home provides a relaxed friendly atmosphere, with a high standard of cleanliness throughout. The home deals with a number of diverse care needs and always ensures to offer a very personalised service to meet all the needs of those using the service. There is a very real commitment to ensure that all users of the service, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. What has improved since the last inspection? Since the last inspection, improvements have been made to ensure that service users monies are protected. The service has for some time had temporary management arrangements in place whilst awaiting the return of the registered manager. The registered manager has now returned to manage the service and has the support of a project worker to assist in the monitoring and administration of the service to ensure that high standards of care are being met and to identify any areas for improvement. The complaints procedure has been updated and provided in picture format to suit the individual needs of those using the service, making it more accessible and understood. Care plans are in the process of being transferred to a new format which is more person centred and in picture format to suit people`s individual needs. What the care home could do better: Some of the training in staff files needs updating, refresher training needs arranging so that staff have up to date knowledge. The registered provider must undertake monthly quality assurance visits to the home , prepare a written report of the findings and the actions to be taken to improve the service. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Follybridge House Bulbourne Road Tring Herts HP23 5HF     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jane Handscombe     Date: 1 7 0 4 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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: Follybridge House Bulbourne Road Tring Herts HP23 5HF 01442828285 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) : alan.wilson@turning-point.co.uk Turning Point Southern Area Office care home 6 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 6 The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - LD Date of last inspection Brief description of the care home Follybridge House is situated in a quiet rural area, backing on to a nature reserve accessible to Service Users. The home has large, attractive and well-maintained grounds, which contain a sensory garden, a trampoline, and swings. The home is part of the charitable organisation Turning Point, which provides residential accommodation for people with learning disabilities and mental health problems. Follybridge House accommodates up to six male Service Users with behavioural problems and learning and communication difficulties. The current fees for this service are #127.85 per week, though this relates only to the residential contribution by the resident, and is only part of the overall fees, with the remainder being paid by the referring authority. Care Homes for Adults (18-65 years) Page 4 of 31 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: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection was conducted over the course of one day and covered all of the key National Minimum Standards for care homes. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion and surveys were sent to people using the service, health and social care professionals and staff. Any replies that were received have helped to form judgements about the service. Information received by the Commission and any visits to the service since the last inspection were also taken into account. The inspection consisted of discussions with the manager, service users and staff, examination of some of the required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising Care Homes for Adults (18-65 years) Page 6 of 31 from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, service users and staff are thanked for their co-operation and hospitality during this unannounced visit. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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 8 of 31 Care Homes for Adults (18-65 years) Page 9 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 10 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a system in place to ensure that all prospective users of the service are provided with information about the service and have an assessment of their needs prior to admission to ensure both parties are confident that their assessed needs can be met. Evidence: All prospective service users and current users of the service are provided with a service users guide, which has been updated since the last inspection. It is produced in both written format and picture format to meet peoples individual needs. The service users guide contains detailed information about the service and enables people who are looking for a home to make an informed choice. Although there has been no new admissions since the last key inspection there is an admission procedure which includes a full assessment. It was evident from records viewed and from discussions with management and staff that the assessed needs of the residents are reviewed regularly. Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: The service deals with a number of diverse care needs and always ensures to offer a personalised service to meet all the needs of their clients. There is a very real commitment to ensure that all clients, however diverse their needs may be, receive a person-centred package of care and support which meets their needs appropriately. Care Homes for Adults (18-65 years) Page 12 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All service users have an individualised plan of care and support detailing their assessed needs and personal goals and how these needs and goals are to be met. Service users are enabled to make decisions about their lives and are supported to take risks in all aspects of their daily lives promoting their independence and choice. Evidence: During the inspection a sample of care plans were inspected and found to be individualised and contain appropriate detailed information on peoples individual needs and preferences and how these needs are to be addressed. Care and support plans are drawn up and reviewed regularly with the involvement of the service user themselves together with family/representatives and other relevant health and social care professionals. Risk assessments are contained within the care and support plans detailing any risks present and how these risks are to be minimised whilst promoting users choices and independence, they were up-to-date, dated and signed. Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: The service is in the process of transferring all service users details into a new style of care plan, which is more accessible to those using the service in that it is in pictorial format and is very much more personalised than those previously inspected. Although these are not yet completed, we were informed that they anticipate to complete transferring all the information within the next couple of months. The residents within the service have limited verbal communication skills, but systems are in place to ensure staff have the information they need to promote the residents decision-making. Service users are encouraged and supported to make decisions about their lives. Choices are made around activities, food and outings through the staff discussing with each individual and using pictures and photographs to support them in making choices and decision making. From the evidence seen and comments received, it is considered that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Care Homes for Adults (18-65 years) Page 14 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 who use the service are supported to access day services, activities and holidays and be part of the community in which they live. People using the service are enabled to maintain contact with family and friends, and are involved in decision making within the home. Evidence: People living in the home are supported to take part in their preferred activities, there are a range of activities provided that service users enjoy. For example one service user has an interest in gardening and during the summer months staff encourage and support him to grow plants and vegetables in the green house situated in the garden. The same service user attends a gardening project giving him with the opportunity to learn new skills and maximise his abilities. Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: Service users attend day centres, where they are able to mix with others, are encouraged to learn and develop skills to their own abilities and provides them with the opportunity to develop friendships within the community. Staff engage users of the service in inhouse activities such as games, puzzles and arrange trips to local places of interest, picnics, visits to local restaurants and bars. The levels of challenging behaviour of the residents living in the home have an impact on the provision of activities but these are managed well. There is a large garden, which the service users enjoy using during the warmer months; it is equipped with swings, a trampoline, a sensory garden and tables and chairs. Service users enjoy their meals and are consulted with about their likes, dislikes and what they would like. All the food is freshly prepared on the premises and provides them with a healthy nutritious diet. One service user has complex dietary needs, which are managed well and input from the dietician and other relevant healthcare professionals is sought when necessary. Pictorial menus have been developed to promote residents choice. Pictorial menus have been developed to promote residents choice. Service users have a limited role in the domestic routines of the home, due to their dependency levels, however they are actively encouraged to take part according to their abilities. Arrangements for service users to meet with friends and family members are flexible and support is given to maintain personal relationships where required. Service users are able to receive visitors at the home, there are no restrictions imposed on visiting unless requested by the service user themselves. People are able to entertain their visitors and friends in their own bedrooms or in the communal areas of the home. Some families live a distance away from the home so the service have supported those service users and accompanied them to visit their families. Care Homes for Adults (18-65 years) Page 16 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are provided with sensitive and flexible support around their personal and healthcares needs. Healthcare records indicated that the health needs of residents are met effectively and the home has good links with external healthcare professionals. The policies for dealing with medicines serve to protect service users health, safety and welfare Evidence: Information about peoples personal support needs and preferences are set out in detail in their personalised care/support plans. Each service user has an individualised plan of care detailing their individual needs and preferences and how these needs are to be met. The service actively involve other professionals or external resources where necessary to assist with any changing support needs of individuals. Each person has a named key-worker who is responsible Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: for ensuring that information relating to the individuals particular likes, dislikes and needs are communicated to all other staff. Since the last key inspection, undertaken in April 2008, the service has contracted some agency staff, the same staff are requested from the agency to ensure continuity of care. All agency staff have an induction and detailed handover, including how to access the support plans for the people living here. This means that each individual is able to receive the support they need with minimal disruption to their routines. Some individuals at the home have specialised health needs, for example, epilepsy. The home ensures that staff members are trained to respond to medical and health emergencies. The home have effective systems in place to manage medication effectively but medicines liable to misuse, called Controlled Drugs were stored stored in a petty cash tin in the drugs cabinet, which does not meet with the Misuse of Drugs Act and for which a requirement has been made within this report to obtain an appropriate controlled drugs cabinet in which to store them securely and affix it to a solid wall or a wall that has a steel plate behing it and it is to be fitted with either rag or rawl bolts to comply with the law. Clear records were kept of medicines coming into the home, medicines leaving the home and medicines given. Medication is supplied in monitored dosage system supplied by local pharmacist. Clear records are kept of all medicines given to people and in situations where medication is not given, this was recorded together with the reason why. There were no gaps or discrepancies on the medication administration charts that we looked at. Service Users records inspected indicated evidence that their views, preferences and needs are taken into account when providing care and support. Service users have the necessary equipment they require to enable them to maintain their independence and robust risk assessments are in place detailing how the care is to be delivered in a safe manner whilst maintaining and promoting the users independence. Of those service users being case tracked during the inspection it was evident that the carers spoken to were aware of their individual needs and had a good understanding of how to address their needs whilst promoting their independence. The healthcare records were generally in good order and included separate records of contact with various healthcare professionals. However, the records indicated that Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: peoples annual health checks were overdue; contact had been made with the GP to arrange for check ups but to date they have not been undertaken. Likewise the service should ensure that peoples dental checks are undertaken. We were informed that there have been problems in accessing a dental service although one has now been found and dental appointments will be undertaken. Information provided in the completed AQAA tells us that the service have identified a shortfall in ensuring that yearly eye tests are undertaken and are presently looking into accessing the services of an optician who will provide the service users with an annual eye test. Care Homes for Adults (18-65 years) Page 19 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 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 and their families know who to contact if they have a complaint. Staff are trained to know how to protect the people who use the service. Evidence: Follybridge House has a complaints policy and procedure in place which is accessible to people who use the service and their relatives. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and who to speak to if they have concerns. The home keeps a complaints log to record any complaints received in which they record details of the actions taken in response to the complaint/concern and the outcomes. Within the complaints book is a section for people to write in any compliments that they have about the service which the manager agreed to review so as to ensure that peoples confidentiality is not compromised. Information provided to us in the completed AQAA informs us that the service have received one complaint during the period under review, which was resolved within the organisations 28 day timescale, however this had not been recorded in the complaints book. The service needs to ensure that complaints are recorded appropriately and to allow for an audit trial. All service users are protected form abuse, neglect and self harm and have all been Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: provided with guidance and support in understanding vulnerable adults issues. All staff are provided with relevant training both in their induction training and regularly thereafter, enabling them to recognise the signs of abuse and how to respond if an allegation or incident is brought to their attention. Likewise they are all provided with and understand their responsibility to use the homes whistleblowing policy if the need should arise. Information provided within the AQAA informs us that the service have made one safeguarding referral, in line with the local interagency policy and procedures, during the period of review. Improvements have been made to ensure service users financial interests are safeguarded. There are robust systems in place to ensure that service users personal allowances and small amounts of cash are safely managed and there are receipts and records for all transactions. Care Homes for Adults (18-65 years) Page 21 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 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 a comfortable, homely and clean environment in which to live. Evidence: A tour of the home found it to be clean, homely and domestic in style with no unpleasant odours. There are limited ornaments, plants etc. in the communal areas owing to aspects of the challenging behaviour of some of the residents. There are two bedrooms and a shower room on the ground floor, with three further bedrooms, a bathroom and staff sleeping in room on the first floor. All bedrooms were found to be decorated and furnished to service users own personal tastes and were clean and personalised with their own posessions and pictures in place. There is a large enclosed, well-maintained rear garden, with swings, a trampoline, garden tables and benches and umbrellas and a sensory area, as well as textured paved paths and areas of lawn, which is used and enjoyed by service users and their visitors during the warmer months. Most of the pathways are provided with handrails. During the last inspection, we highlighted the need to address the gap around the perimeter of the trampoline to ensure that people are free from risk when using the Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: trampoline. In discussion with the manager during this inspection we were assured that they are in the process of acquiring some sandbags to fill the gap to ensure that people are free from harm and in the meantime staff accompany the service users in the garden. The service have improved the security of the garden area, in that the fencing in the back garden has been repaired since the last inspection. The service are in the process of purchasing some new furniture to add comfort for those using the service, which includes dining tables, chairs and curtains for the lounge and dining room and plan to purchase some more equipment for the sensory room, which has recently been redecorated. Care Homes for Adults (18-65 years) Page 23 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. robust procedures take place when recruiting and selecting staff to ensure the service users health, well-being and security. Application forms are completed, references are collected face-to-face interviews are undertaken. Relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken to ensure the persons suitability with working with vulnerable people. Evidence: Follybridge House has a committed and stable staff team. Staff spoken to confirmed that the team are very well motivated and work hard to improve the lives of the people who use the service. People commented in surveys that they were generally satisfied with the service and the staff. Reruitment files are kept at the organisations head office as per an agreement with the Commission. Information from previous inspections and discussions with the manager and staff informs us that robust procedures take place when recruiting and selecting staff to ensure the service users health, well-being and security. Application forms are completed, references are collected face-to-face interviews are undertaken. Relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken to ensure the persons suitability with working with vulnerable people. Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: Whilst inspecting a staff members personnel file, who had been recruited since the last key inspection we undertook, it was noted that there was no documentation within the file to evidence that a robust recruitment procedure had been undertaken as these were held at head office.Since the recruitment files are not held on site we reccommended that each staff members personnell file contains a declaration to acknowledge that all the required documentation is in place and this be signed by the registered manager to acknowledge he/she has seen the appropriate documentation, to which he agreed would be in place for each staff personnel file held in the service. All new members of staff are provided with induction training and shadow experienced staff until both parties feel confident in undertaking the role unsupervised. Staff are provided with mandatory training, offered ongoing training and encouraged to undertake the National Vocational Qualification (NVQ) in Care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. Information provided to us during the inspection informs us that of the nine permanent care staff four have obtained their NVQ qualifications at level 2 or above in care. Staff have a clear understanding of their roles and responsibilities and demonstrate a good sense of team work. Records are kept of staff training and show that staff receive the training needed to meet the needs of people living at Follybridge House. This training includes induction, health and safety, fire, first aid, food hygiene, protection of vulnerable adults, sexuality, moving and handling and medication. Staff have also received specialised training to enable them to administer the appropriate medication when people have severe seizures. Records confirmed that staff have regular supervision and appraisal and that staff meetings are held. Staff confirmed that they feel well supported and have the opportunity to discuss any concerns with the management team. Care Homes for Adults (18-65 years) Page 25 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home aims to promote continuity and good overall personal care for the people who use the service Evidence: The manager obtains feedback from residents and visitors when talking to them in the home, and has an open door policy that encourages people see him without the need to make an appointment. Regular monthly residents meetings are held to gain the views of those using the service and through the homes annual quality assurance system in which surveys are sent to relatives, residents, staff and other stake holders. The home has sent out questionnaires a fortnight prior to this visit, which included pictorial surveys for those using the zervice, and are awaiting their return. Information provided in the completed AQAA informs us that a representative of the organisation visits the home regularly and monitor standards which includes examining care plans, fire log training procedures, the administration and recording of medication and other health and safety issues and speaks to residents and care staff alike to gain Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: their views on the standard of care provision. However, the service did not have documented evidence of visits undertaken since June 2008. . These visits should be undertaken in line with Regulation 26 of the Care Homes Regulations and records be kept of each visit to monitor the quality of service being provided to those using the service. The home has a health and safety policy statement and provides training and equipment for staff. Safety checks relating to fire safety and infectious diseases are regularly carried out. The home sent us their annual quality assurance assessment (AQAA) when we asked for it. It was clear and gave us all the information we asked for. The AQAA contains clear, relevant information that is supported by a wide range of evidence and informs of areas in which they plan to make improvements over the next 12 months. It was noted that information provided within the AQAA highlighted that some of the policies and procedures have not been reviewed for some time, which we fedback to the manager and project worker, who agreed to revisit the homes policies and procedures and review and update those that required. Care Homes for Adults (18-65 years) Page 27 of 31 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 28 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 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 20 13 Ensure that a controlled 31/07/2009 drugs cupboard, which complies with the misuse of drugs (safe custody) regulation 1973 is provided for the secure storage of any controlled drugs which are prescribed for people who use the service. To ensure the safe storage of controlled drugs 2 39 26 The registered provider 31/07/2009 must undertake monthly quality assurance visits to the home and prepare a written report of the findings and the actions to be taken to improve the service. To identify any areas of concern and monitor the quality of the service provided. Recommendations These recommendations are taken from the best practice described in the National Care Homes for Adults (18-65 years) Page 29 of 31 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 Textphone: 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. 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