Care Home: Highfield Hall

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• 10 Whitfield Avenue

What the care home does well You like living at the service and like the staff.You have good care plans that you and the staff put together. These show the support you need.The staff give you information in different ways to help you understand things more easily.You can choose the things you want to do like going out to places and taking part in activities.You can choose where to go on holiday.You can go to church if you want to.You see the doctor when you are ill and have regular check ups with the dentist and the optician.You meet with the staff regularly so you can tell them what you want and if there any problems.The home is a nice place to live. You all have your own bedroom. You can have lots of your own things in your bedroom. What has improved since the last inspection? The service has better information to tell people what the home offers.The home makes sure you have the right medication.The service has improved the way it recruits the staff. This will make sure that you are made safer. What the care home could do better: The home should record when you are weighed so that they can check you keep healthy.The lounge in The Hall should be decorated as this would provide you somewhere nicer to sit. Key inspection report Care homes for adults (18-65 years) Highfield Hall Name: Address: Highfield Hall Stafford Road Uttoxeter Staffordshire ST14 8QA two star good service The quality rating for this care home is: 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: Jane Capron Date: 1 0 0 6 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 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 Information about the care home Name of care home: Address: Highfield Hall Highfield Hall Stafford Road Uttoxeter Staffordshire ST14 8QA 01889563780 01889566902 info@moorcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Rushcliffe Care T/A Moorcourt Developments Ltd care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 21 2 0 0 learning disability physical disability Additional conditions: Abbey View - Six beds - Learning Disability (LD) Highfield Hall - Nine beds - Learning Disability (LD) and Two beds - Physical Disability Kingston View - Six beds - Learning Disability (LD) Date of last inspection 1 0 0 6 2 0 0 8 A bit about the care home 21 people live in this home. Everybody has their own bedroom. The home has a large garden and the home grows vegetables and keeps hens. There are places to sit outside. The home has its own transport that everyone can use. The home gives people information about what the home offers. 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 How we did our inspection: This is what the inspector did when they were at the care home We spoke to 3 people to see if they liked living at the home. We spoke to staff that work at the home. People sent us surveys about what they thought about the home. We spoke to some relatives that were visiting the home. We looked at some care plans and other documents about the home. What the care home does well You like living at the service and like the staff. You have good care plans that you and the staff put together. These show the support you need. The staff give you information in different ways to help you understand things more easily. You can choose the things you want to do like going out to places and taking part in activities. You can choose where to go on holiday. You can go to church if you want to. You see the doctor when you are ill and have regular check ups with the dentist and the optician. You meet with the staff regularly so you can tell them what you want and if there any problems. The home is a nice place to live. You all have your own bedroom. You can have lots of your own things in your bedroom. What has got better from the last inspection The service has better information to tell people what the home offers. The home makes sure you have the right medication. The service has improved the way it recruits the staff. This will make sure that you are made safer. What the care home could do better The home should record when you are weighed so that they can check you keep healthy. The lounge in The Hall should be decorated as this would provide you somewhere nicer to sit. 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 Jane Capron 77 Paradise Circus Queensway Birmingham W Midlands B1 2DT 01216005300 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 http:/www.cqc.org.uk/. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535. 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 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 that live at the service can be confident that the service will assess their needs before they move there to ensure that they can meet their needs. People living at the service are given information about what the service offers but information needs to be always up to date. Evidence: The services Annual Quality Assurance Assessment (AQAA) states that each person is given information about the service and that this is provided in both a written and pictorial way to try and make it as accessible as possible. The AQAA also states that people can visit the service before decoding if they want to live there. Copies of information are provided to everyone that lives there. The service has a service user guide but we feel this needs to be updated to incorporate information about what the service offers and includes changes that have occurred particularly relating to how the cost of transport is arranged. There have been no admissions since we visited last time. However we did see on file copies of assessments completed before people moved to the service. The service ensures that it obtains a copy of the multi-agency assessment before considering anyone for a place at the service. The service also visits prospective people to complete their own assessment before decoding whether they can meet someones needs. The assessment looks at peoples health and personal care needs, any mobility issues, communication needs as well as any cultural and spiritual needs. The service also considers their individual likes and dislikes. The service ensures that it involves the people that currently live at the service taking into account their views. Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service can be confident that plans of care are in place to provide staff with the information they need to provide their support in the way they want. People can be confident that they will be encouraged and supported to make decisions about how they live their lives. Evidence: The AQAA tells us that each person has a person centred care plan and that people are involved in developing their own plan. The AQAA also states that the service supports and encourages people to make decisions about their life. Sampling shows that people have care plans in place. These include information provided in a person centred way. The plans show information in a easily accessible way including for example the use of pictures. The plans include information about the support people need with their health and personal care needs, specialist communication needs, eating and drinking, mobility issues and show the things people like to do. The plans show peoples hopes for the future and include action plans to support people to achieve them. Care plans provide staff with the information to support people in the way they want. Care plans are reviewed and updated. Risk management systems are in place to provide people with the support they need to live their lives without being placed at unacceptable risk. One person for example eats in such a way that they could be at risk of choking. The staff make sure that they are given a small amount of food at a time and that food is cut up. Another person needs support with bathing due to the risk of them having a seizure. Talking to people shows that people make decisions about how they live their lives. For example people living in Abbey View say that they help to choose their meals and in we saw people living in The Hall being given a choice of meals. One person did not like either of the meals on offer and asked for and was given something different. People also tell us that they choose where to go on holiday. They tell us that the staff provide them with brochures to choose holidays from. In addition one person said that she looked through a catologue as she wanted a new TV. She then went with staff to go and buy one. We also saw in the records that the service had involved an advocate with one person who Evidence: needed support to make a decision over a health care issues. The service supports some people with specialist communication needs and when we spoke to staff they could tell us about how they helped these people make choices. For example one person who does not communicate verbally makes her wishes known by taking staff to show them what they want. Another person uses pictures when she goes shopping to show the staff and shop what they want. People that live at the service also meet with staff and the manager regularly providing them with the opportunity to make their views known. The service also tells us in the AQAA that they have changed the meals in response to the views of the people that live there. People take part in aspects of running the service. In Abbey View people tells us that they help with cleaning their bedrooms and the communal rooms, they help with ding the food shopping, help with cooking, and laying and clearing the table. People in the other units take part in activities according to their abilities. For example in both The Hall and Kingstone View people help to lay and clear the table and are involved in deciding on menus. 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 that live at the service are supported to take part in activities of their choice. People can be confident that they will be provided with a varied menu and that they have a choice of meals. Evidence: The AQAA states that the service provides people with the opportunity to take part in a range of activities both in and out of the service. We saw that people are encouraged and supported to live a varied lifestyle. The service has an activity staff member who supports people to take part in activities at the service including arts and crafts and doing puzzles. We saw that people had made notices for their bedroom doors and place mats. The service has its own vegetable garden and chickens and people said that they grow vegetables. The service also supports people to regularly access the community. One person said they went horse riding, another said they sometimes went swimming and another said they sometimes went to the gym. One person said they were from Shropshire and that the staff took them to visit where he used to live and when he went shopping he choose to go to Market Drayton because he knows the area. People tell us that some of them go to a keep kit session, to the Gateway club in Leek and to college. Several people showed us pottery they have made. People said that they go out to play bowls, go out for meals, picnics and trips out. Pictures of trips out are on the walls. Several people said that they go to church. People have the chance to go on holiday. Some people have already been and another group are due to go in the near future. The service now has its own transport which the people living there contribute towards. The manager tells us that the new payment arrangements has been agreed by the people that live there or their representatives as appropriate. Residents are supported to develop and maintain relationships with friends and family. We spoke to several relatives who were present during our visit. All are complimentary about the service, feeling Evidence: that their relative is well cared for. They tell us that they are made welcome at the service and that the staff encourage them to visit and keep in contact with their relative. We also saw in records that staff support people to buy cards and presents for relatives. One person said that he regularly sees his family and another person said that his family regularly telephone him. During the day we were there went to see people in other units. We saw that the routines within the units are relaxed. People are encouraged to spend time where they want. People can go and spend time either in the communal rooms or in in their bedroom. We observed meals being taken and there is a relaxed atmosphere with people and staff chatting together. The services AQAA states that it provides people with a choice of a healthy diet and people appear to enjoy meals and mealtimes. We saw that the service provides people with a choice of meals and that the menus are varied. We saw that fruit is available in the units. People tells us they like the meals. In one unit where people are more independent they decide on the meals and go with staff to do the food shopping. This unit is involved in preparing the food, clearing up and washing up. People that need support to eat are provided with it and people have equipment such as lipped bowls to be able to eat independently. Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service can be assured that they will be supported to have their health and personal care needs met. People can be confident that the service will administer their medication correctly. Evidence: The services AQAA states that each persons plan of care includes their health care needs and that the records show that people are seen by health care professionals as required. Examination of care plans shows that the service identifies the personal care and health care support people need. Records show that people receive dental and eye checks and that they regularly see a chiropodist. People that live at the service confirm that they have regular health checks. Records also show that when people need specialist health care services they are supported to receive them. For example one person may have needed a small medical procedure and the service involved an advocate to help the person to understand and decide if they wanted to go ahead with the procedure. The service has a procedure in place for weighing people but it was unclear over the regularity of weighing as there are some quite lengthy gaps in the records. We raised this issue with the manager. Information from a health care specialist said that the service refers people appropriately and commented the clients needs appear to be well catered for. The manager always consults the [health] team for advice and support and acts on the advice given. A doctor that responded to our survey said they feel that peoples health care needs are properly monitored, reviewed and met by the service. They said patients are brought for their medical problems in a timely and appropriate way. We observed that people look well groomed. People have their hair attended to either by going to the hairdresser or by a hairdresser that visits the service. People tell us that they choose and buy their own clothes supported by care staff. The service is respecting peoples privacy and promoting their dignity. Staff knock on bedroom doors before entering and ensure that doors are closed when people are having personal care tasks attended to. We spoke to three staff members and they could tell us how they made sure that peoples dignity was promoted. Comments included making sure door and curtains are shut and ensuring are not left uncovered when waiting for a bath or during drying . One staff commented I treat people like I Evidence: would want to be treated. Relatives of people living at the service are very pleased with the care provided. Comments from our surveys include the staff look after all her needs very well - both medically and personally and the service looks after my daughter well. Whilst at the service we met several relatives and they are highly complimentary about the service with comments such as brilliant, have peace of mind, couldnt get any where better and care excellent. The services AQAA states that they have a medication procedure in place and that this is audited. They also state that staff are trained in the administration of medication. We saw that a local pharmacist has checked the medication arrangements at the service and is satisfied with the way the service manages it. They made no recommendations for improvement. We also checked the arrangements in place for the administration of medication. Medication is stored securely and there is no excess of medication. The service has a stock control system in place. We did a check of two peoples medication and found it was being administered and recorded correctly. One person has some medication on an as required basis and a protocol is in place to inform staff when this should be administered. Records and talking to staff shows that all staff that administer medication are trained. 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 that live at the service can be confident that they will be listened to and that the staff will act on what they say. People can be assured that staff have knowledge adout safeguarding issues and will act to keep them safe. Evidence: The services AQAA states they act on concerns and complaints raised and that staff are trained in safeguarding issues. Information about how to make a complaint is provided to people in the information provides to people and is displayed in the entrance area of all the units. It is provided both in written and picture form. People we spoke to said if the had a problem they would tell a senior carer or Lee, themanager. The responses to our surveys shows that people know how to make a complaint. The service has systems in palce to listen to the views of people living at the service. Regular house meetings are held and annual surveys completed. The serivce says it has changed the menus and activities as a result of listening to the views of people that live there. Neither the commission or the service has receved any complaints since we visited last. We talked to staff about their awareness of safeguarding issues. All the staff we spoke to are aware of signs of abuse and are clear over the action they must take if they have any concerns. We looked at the arrangements the service has for making sure peoples money is kept safe. A check of two peoples money shows that the service keeps accurate records, maintains receipts for money spent and undertakes regular internal checks to ensure that peoples money is protected. Some people that live at the service have behaviours that challenge. There are procedures in place to respond to such incidents and some staff have had training in dealing with challenging behaviour. We spoke to some staff over how they deal with difficult behaviours and they tell us that the response to each person is different and is based on what has been shown to be effective in the past. Since we visited last there have been no safeguarding incidents. 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 can be assured that the service provides good private and communal accommodation that meets their needs. People can be confident that the service has procedures in place to keep the service clean and to control the risk of infections. Evidence: The AQAA states that the service provides people with a safe and comfortable place to live. It states it has good private and communal rooms that are all wheelchair accessible. It also states that bedrooms are individualised by their occupants. The service also tells us that it now has an assisted bath in one unit and that some bedrooms have been decorated. We looked at a sample of accommodation in each unit. This confirms that the service overall provides good accommodation. Each unit has a lounge, kitchen and dining area. Accommodation, excluding the kitchen in The Hall which is of a more catering type, is domestic in style providing people with comfortable surroundings. We did see that the communal lounge in the Hall did need decorating. The area particularly round the doorway has been subject to a lot of wear and needed repainting and wallpapering. We also feel that some of the bathrooms could be more welcoming. The majority of bedrooms have their own washing and toilet facilities. There is a bathroom and shower room in each unit. Bedrooms provide good private accommodation. People tell us they like their bedroom. People can personalise their bedrooms and bedrooms we saw contain a lot of personal items of the occupants including TVs, CD players, photos, pictures and ornaments. One person said that they have recently been out to buy themselves a new television. Due to one persons specific needs their room was less personalised although this person has lots of belongings these are not on show. Each unit has its own laundry facilities. Units are clean and tidy and staff tell us that there are infection control procedures in place and that protective equipment is always available. The responses to our surveys tells us that people find the service clean and fresh. 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. A well trained and consistent staff team support the people that use the service and keep them safe. Evidence: The services AQAA states that people that live at the service are supported by staff who are well motivated and knowledgeable and who are trained and qualified. Observation and talking to staff show them to have positive relationships with the people that live there. In one unit staff and people living there were sitting having lunch chatting together. Staff we spoke to are aware of persons needs including any communication needs. People tell us that they like the staff. One person that lives at the service said in a survey that the staff are all good workers. All the survey responses said that the staff treat people well and listen to what they say. Comments about the staff from relatives we spoke to include staff great and will do anything for the people that live there. Staff we spoke to said that they have received relevant training including health related issues including diabetes and epilepsy. Sampling of staff files confirm that people receive induction and ongoing training. Staff do however need to have more knowledge about the provisions of the Mental Capacity Act including the Deprivation of Liberty provisions. The services AQAA states that 16 of the 23 staff have an NVQ qualification. The staffing levels are sufficient to meet the needs of the people that live there. Each unit has a minimum staffing level, two staff in each unit. The rosters show these are always adhered to and that there are often thee staff working in The Hall. The manager does tell us that he occasionally needs to work as a care staff member to cover for example sickness. However he states that this is not a regular occurrence and does not affect his management responsibilities. An activity staff member works with the care staff to support people in all units to take part in a range of activities both in and out of the service. The AQAA states that their recruitment process ensures that people provide two re fences and a Criminal Records Bureau (CRB). Sampling of four staff files shows that in all cases a CRB and Protection of Vulnerable Adult( POVA) check has been obtained. Three of the four files contain two references. Where one reference is present there is evidence that a second has been requested. The manager confirms that this will be followed up immediately. 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. People can be confident that the service is run in their interests and that the services health and safety practices are protecting them. Evidence: The AQAA tells us that the manager is qualified and experienced. It states that the manager relates well to people that live there, staff and relatives. It also states that the manager knows the needs of the people that live there and takes an active part in daily activities believing that he should lead by example. The manager has long experience of working with people with a learning disability and is well regarded for his knowledge and for promoting the rights of people with a learning disability. He is a member of the Staffordshire Social Care Workforce Partnership (SSCWP) that develops and promotes training for care staff to improve local care services. Staff we spoke to are positive about the manager seeing him as fair and firm and putting the needs of the people that live at the service first. Relatives hold him in high regard. Comments include Lee is brilliant, couldnt get better ,he puts himself out for the people that live here. A health care professional also gave us positive comments about the manager saying the current manager is very capable and provides a very good service. The service provided us with an AQAA. This gave us information about the service and their plans for the future. We did advice the manager on how this could be improved. Systems for monitoring and reviewing the service are in place. These include gaining the views of people that use the service, relatives and professionals that visit the service. The service audits areas of its service including checks on the environment, an analysis of accidents and an external audit of the arrangements for administering medication. The service undertakes regular safety checks. The AQAA confirms that checks are made on electrical and gas equipment as well as on the vertical lift. The examination of the fire records confirm that the alarms and emergency lighting is regularly checked and that fire drills are held. A fire risk assessment is in place. Accidents are recorded but we advised the manager to record fuller details of actions taken Evidence: to address any issues resulting from accidents. Staff receive training in health and safety issues. Senior managers from the company visit the service to undertake monitoring visits. These should be recorded but no copies of visits were available after February 2009. 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 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 1 1 People living at the service should be given up to date information about what they can expect from the service and include any changes in how the service is run. Where it has been decided that people need weighing this should take place and be recorded. This will make sure that any significant weight changes are identified and appropriate action taken. The lounge in The Hall should be decorated. This will provide people with more pleasant accommodation. Staff should have knowledlge of the Mental Capacity Act including the Deprivation of Liberty provisions. This will ensure that peoples rights are always promoted. 2 19 3 4 28 35 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. 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