Care Home: Kingswalden Villa

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What the care home does well The service has a friendly and welcoming atmosphere. People who use the service are clearly the focus of care delivery and it very much their home: decor and furnishings reflect their tastes and we observed that they run their house as they wish giving direction to the staff. The ethos of the service is about people who use the service maintaining their independence and moving onto more independent living if they desire. Staff work hard to facilitate this and there is a `can do` approach to people who use the service`s request resulting in a positive atmosphere. What has improved since the last inspection? The medication system has greatly improved. At the previous inspection there were some errors in recording amounts, signing to reflect administration of medication and ensuring adequate medication was available. This has been resolved. 2 people who use the service are hoping to move into `supported living`. Two other people have developed a relationship and are planning their future. One person has purchased a bike and commenced cycling proficiency sessions. What the care home could do better: The absence of a manager has impacted upon the necessary documentation to illustrate how positive outcomes are achieved. The acting manger has maintained stability and consistency but has worked in their role of senior and acting manager for 5 months and had no deputy to support their work. People who use the service currently have no access to daily notes that are written about them to determine whether their support plan is successful or not. They have access to other information but it is in it`s final version. Work is ongoing but it is not always possible to identify how positive outcomes have been achieved. Bread is kept in the office and there is no protocol under the Deprivation of Liberty aspect of the Mental Capacity Act guidance. The medication system has improved but we found food being stored along side Insulin in a medication fridge. This poses a risk of cross contamination. The complaints records were incomplete and the local safeguarding procedure had not been adhered to. The Care Quality Commission had not been notified of a safeguarding incident or the return of the registered manager from sick leave. Key inspection report Care homes for adults (18-65 years) Name: Address: Kingswalden Villa 40 The Baulk Biggleswade Bedfordshire SG18 0PX     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Angela Dalton     Date: 0 2 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 30 Information about the care home Name of care home: Address: Kingswalden Villa 40 The Baulk Biggleswade Bedfordshire SG18 0PX 01767318674 F/P01767318674 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: www.hft.org.uk HF Trust Ltd care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Kings Walden Villas is one of five registered care homes within Bedfordshire that are managed by Home Farm Trust. HFT is a nationwide provider for people with learning disabilities. Kings Walden Villas is situated in a residential area of the market town of Biggleswade, and is a short distance from the local HFT headquarters and day care facility in Shefford. The home is within walking distance of the towns shops, public houses, cafes, and bus and rail links. A leisure facility with swimming pool is a short car journey away. The home does not have off road parking. The building was originally used as a private domestic dwelling. It has been sympathetically converted to retain its homely environment, and provides single accommodation to eight adults with learning disabilities organised on two levels. Communal space consists of toilet and bathing facilities, a lounge, dining room, and kitchen. In addition, at the rear of the property is an all weather conservatory that leads to a small-enclosed garden. Within the garden, is an outbuilding used for storage and laundry. The home is not currently adapted to accommodate people with physical disabilities. The home is registered for 7 beds. Care Homes for Adults (18-65 years) Page 4 of 30 Over 65 0 7 1 6 0 1 2 0 0 9 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: One inspector conducted this unannounced site visit on 2nd November 2009 between 10.50 am and 5.00pm. Two people were case tracked. We followed the care of people who use the service to ensure the care they receive is reflected in the care plan and meets their individual requirements. The case tracking process cross references all the information gathered to confirm that what we are told is happening is actually occurring, and, reflects the Statement of Purpose, which contains the aims and objectives for the service. We spoke to the people who use the service and members of the staff team. The manager was on a day off but we spoke to them following the inspection to provide an overview of the site visit. We conducted our inspection with the senior support worker. We received some surveys from people who use the service and their comments have been included in the report. We were present for lunch and observed interaction Care Homes for Adults (18-65 years) Page 5 of 30 between staff and people who use the service. We toured the building and examined documentation to check that what was happening in the service was being recorded. The services weekly fees currently range from 606.36 pounds to 755.14 pounds. This does not include toiletries and private chiropody and other personal expenses. Care Homes for Adults (18-65 years) Page 6 of 30 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Care Homes for Adults (18-65 years) Page 7 of 30 order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The necessary information is in place to enable people who use the service to make an informed choice about moving in. Evidence: There have been no new people moving into Kingswalden Villa since the previous inspection. Two people are planning to move onto supported living. Their needs are assessed on a regular basis and they are involved in devising their own goals to enable them to live more independently. Each person who uses the service had a service users guide in their care plan folder. This contained information about the home and local area and facilities and had photographs to illustrate the information. It also made it simple to understand for people who use the service who have difficulty reading. Some people who use the service had moved into the area and found the service users guide helpful in providing information about their new home and local facilities. The statement of purpose is equally as informative and this is reviewed each year to ensure that all the information is current and correct. Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: Staff are using the computer system to record information. There are still plans to review all documentation to ensure that it is as user friendly as it can be. Service users do not have access to all the information that is recorded about them. This was raised during the inspection and CQC has been assured that there are plans to introduce information in an accessible way. A reassessment is completed each year so that the person using the service can be assured that their needs are being met and any new developments are included. Information is entered on the computer by staff but people who use the service do not currently have access to their daily notes and information that is written about them. Staff told us that they could print notes off and that the content was discussed with people who use the service. Each person who uses the service has a person centred plan which identifies hopes, dreams and aspirations and how staff can help them to be realised. The aim of the service is to enable individuals to develop their independence and move into supported living accommodation. This has successfully occurred with previous people who use the service and two more people are planning a move in future. Care Homes for Adults (18-65 years) Page 11 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. It is evident that people who use the service make decisions about their care and how their home is run but there is not always sufficient evidence to support this. Evidence: Staff record information on the computer system:SPARS - Support Planning Assessment & Recording System. This aims to streamline the recording of information. Staff record information directly upon the computer. As there are no paper records service users do not have access to day to day information written about them. There are plans to introduce a service user friendly system but this is not in place. It is not easy to identify whether there are improvements or deterioration with individual needs. Daily notes are transferred on the system into a reassessment of need which is reviewed annually. This is updated annually and describes each person who uses the service, their needs, daily routine, likes and dislikes. However, we noted gaps in information. One person has a risk assessment relating to knives being locked away. This is currently being reviewed but there was no update to the risk assessment Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: of guidelines in place. Staff told us that there have been discussions to review this decision but an outcome has not yet been decided. Bread is still kept in the office and there was no evidence of the protocol to reflect how this is reviewed or attempts made to manage the reasons why it is stored in the office. Staff told us that they had received some training on Deprivation of Liberty as part of the Mental Capacity Act. There was no formal assessment to illustrate why bread is not kept in the kitchen and how this issue is monitored, managed and reviewed. Generally, risk assessments reflected how individuals were assisted in managing risks. They are also used in a positive way in helping people who use the service move towards their goals. One person who uses the service has now purchased a bike and is being supported to attend cycle proficiency training sessions which will result in increased levels of freedom and independence. At the previous inspection staff were assisting the person to find a bike and source cycle proficiency support. Two people in the service have chosen to share a bedroom. There was no evidence of discussions being made around shared occupancy, sexual health, access to the bedroom and staff and service user boundaries. This information would reflect that people were not vulnerable and that they had made an informed choice. We looked at 2 care plans. Information is recorded regularly and if significant but not daily as people who use the service have lived there for between 3 and 10 years and staff have a good understanding of core needs. Each person who uses the service has a person centred plan which identifies their wishes and aspirations: this enables staff to know the goals that they are working towards. Each person who uses the service has a monthly meeting to review how their goals are being met. People who use the service receive support from various health and social care professionals and this is reflected in the care plans. The Advocacy Alliance is available for people who use the service if they require independent support. Care plans reflected that useful information had been received from them e.g. a fact sheet about criminal bureau checks. Important family information was recorded such as birthdays and the help that was needed to by a card or small present. End of life plans are ready to be completed and are in each care plan. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make choices about their lifestyle and how they spend their leisure time. Evidence: The ethos of the service is to develop and maintain independence, enabling those who wish to move into supported living. This has occurred with former occupants and as stated previously, care plans facilitate this process. One person told us that they were learning how to cook to enable them to move out. Another person told us that they take turns cooking dinner to ensure everyone gets to use the kitchen and practice their skills. The house is run by people who use the service and they determine what they do and request staff support when needed. People who use the service attend college and work placements with staff support or independently.The service has access to a car but people also walk or use public Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: transport. Each person who uses the service has a mobile phone to maintain contact should they have any concerns but most use it to inform staff they are on their way home. People who use the service use the community facilities frequently: they go to the pub, cinema and shopping as well as attending clubs each week which enables them to meet friends. Those who choose to attend church independently. Care plans reflect individual leisure activities and staff facilitate them. There was an advert for future activities displayed accompanied by a photograph which some people who used the service planned to attend. Choices are made in house meetings and people who use the service use their meetings to make decisions about the running of their home, their holidays and leisure activities. People recently went on holiday to Kent and Portugal. As stated earlier, people are able to form relationships and choose who to spend their time with. Each person who uses the service has an allocated day to complete their laundry and all participate in household chores and preparing meals. One person who uses the service told us We have a jobs rota and do different jobs on different days. We all take turns using the laundry. Menus are decided by each individual with one person choosing meals on various days. This system works well for everyone as they choose to eat what they like and alternatives are available. The staff team have previously worked with the psychology team to overcome the difficulty of people who use the service taking bread and hiding it or eating all the bread available. Various approaches have been tried to remedy the situation but as discussed earlier in the report there is currently no protocol that is reviewed in place. Until a solution is found bread is kept in the office with a supply of crackers, biscuits and fruit available throughout the night. We spoke to people who use the service and they knew why bread was kept in the office. They told us that they could come and get bread when they wanted to. One person told us that they were ok about bread being kept in the office. Care Homes for Adults (18-65 years) Page 15 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans reflect individual health and social care needs, however medication storage does not safeguard people who use the service. Evidence: Care plans and reassessments reflected how people who use the service wish to be supported but as stated earlier people who use the service do not have access to notes recorded by staff unless a request is made. Personal preferences are reflected and discussed in individual meetings. The previous keyworker system has been altered and individuals are no longer allocated a key member of staff. People we spoke to stated that they felt supported and able to talk to various members of the team. People who use the service are supported to manage their health. One person was supported to visit the G.P. during the inspection and told us that they had been well cared for whilst feeling unwell. Staff are able to seek support from members of the multi disciplinary team when Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: necessary Each person who uses the service has an individual health plan and illustrates that each individual receives support form various health and social care professionals. This has been reviewed since the previous inspection as have self medication protocols and guidance. Health Action Plans and self medication guidance is kept together to ensure that information is kept up to date. This has improved since the previous inspection and there is an accompanying risk assessment demonstrating that the person who uses the service is competent to self medicate. This was only present for one person who self manages their diabetes and insulin injections. Staff had received training and worked in partnership with the individual to maintain their independence. Medication is stored at the correct temperature and records reflected this. Unfortunately a container of cooked takeaway noodles and a pack of cheese were being stored in the medication fridge. This is not appropriate as contamination between food and medication (Insulin) may occur. Copies of prescriptions are kept to show receipt of medication. A controlled medication cabinet was fixed to a wall during the inspection, but controlled drugs are not currently used in the service. Medication records have improved since the previous inspection. The Medication Administration Record sheets (MAR) reflected that if medication is checked out the amounts are recorded to ensure that a balance can be recorded on return to the home. MAR sheet instructions have improved and now advise of the route, start date and amount of medication prescribed. As required(PRN) medication is reflected and given appropriately. Nutritional guidelines were in place for staff to follow and are kept in the kitchen to enable staff to appropriately support people who use the service. Care Homes for Adults (18-65 years) Page 17 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Evidence was not in place to illustrate how people who use the service are protected from harm. Evidence: The complaints policy reflected that people who use the service were able to raise concerns. A complaint had recently been made but there was no evidence to reflect what action had occurred and how the complaint had been dealt with.It was evident that a Safeguarding referral should have been made but this had not occurred although the situation had been addressed. All staff have received training on safeguarding vulnerable people and staff who received the complaint referred it to senior management. As discussed earlier in the report two people who use the service have chosen to share a bedroom. There is no evidence to reflect that people who use the service are not vulnerable and have made an informed choice. There was no written evidence relating to the complaint, what action was taken or the outcome in the service. We were told that records had gone to the regional office but a copy had not been left in the home. This differed from the positive findings at the previous inspection. People who use the service told us that most issues are resolved at house meetings or one to one meetings. There is the facility for people who use the service to access independent support from the Advocacy Alliance if they wish. We Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: received 4 completed surveys from people who use the service and all reflected that they knew who to speak to if they were unhappy. We checked financial records and found them to be in good order. The service uses a specialised system (Versapak) which has a separate number for a lockable tag. Each time finances are checked a new tag is issued with a corresponding number. Care Homes for Adults (18-65 years) Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides a clean and comfortable environment to live in, which encourages independence. Evidence: Development to neighbouring property is currently impeding the resurfacing of the driveway and having a gate fitted. Once work on the development has ceased these issues will be addressed. The service was clean and tidy with the exception of a communal lounge. One service user had slept on the settee for 2 nights as they felt that the smell of paint from their newly decorated bedroom was overpowering. They have since returned to their bedroom to sleep. Staff are working with them to tidy their collection of videos that is currently taking up floorspace in the lounge. There is a homely and friendly atmosphere and the service is personalised by the people who live there. The house feels very homely and has the personalities of the people who live there reflected in the decor. Bedrooms were personalised and locked when vacant. There are activities around the building which are utilised - there is a computer available for people who use the service to access. There are also computer games, a playstation and DVDs. 2 people who use the service have their own Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: computer and use it to download music etc. The service has a WiFi (wireless) for people who use the service to access with their laptops. There are plans to update the homes fire plan to reflect 2 service users revised sleeping arrangements. The toilet seat that was broken at the previous inspection has been replaced. Doorguards have been on order since the last inspection for the office to ensure that the door will close in the event of a fire. Staff and service users were unable to confirm if the conservatory was still leaking there was no evidence of damp despite the heavy rain the previous evening. Staff plan to investigate whether the fuzzy television picture in the conservatory can be improved. Care Homes for Adults (18-65 years) Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience 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 receive support from competent and trained staff. Evidence: There have been no new staff employed since the previous inspection - one staff member has left but their hours have been covered by employing an existing bank member of staff. We were sent records of training following the inspection as the manager was off on the day we visited. A variety of mandatory and non mandatory training has been completed by staff The manager has updated the training matrix to reflect the variety of training completed e.g. food hygiene, safeguarding vulnerable adults, Mental Capacity Act, medication training. All staff complete the Learning Disability Award Framework induction and foundation. This equips them with specialist induction training which enables them to progress to completing NVQ qualifications. 3 staff are working towards NVQ level 2 and 2 staff have achieved level 3. There is a stable core of staff. Staff told us that they enjoyed their job and working with people to help them become more independent. People who use the service told us staff help sort out my problems. They help us. They help me when I ask. The home cares. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: The on call is available out of hours and is only half an hour response time away. Care Homes for Adults (18-65 years) Page 23 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager ensures that the focus is upon people who use the service but there is evidence that the Care Homes Regulations are not adhered to. Evidence: The manager has worked at the home for several years and is supernumerary to the numbers of staff rostered on each shift. They have recently been off sick for five months. During this time a senior support worker took over the role in an acting capacity. This was in addition to their own role and having no-one to deputise during this time. Staff and people who use the service confirmed that they maintained the smooth running of the home and there was little disruption to normal service. The manager has relinquished the role of managing a supported living service and manages Kingswalden Villa for 25 hours each week. Home Farm Trust are seeking clarification with the Commission regarding part time management. We have spoken to the manager since the inspection to provide feedback regarding our visit.The manager is aware that there have been shortfalls in keeping the Commission of developments but some issues have occurred in their absence. Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: The AQAA (Annual Quality Assurance Assessment) was completed prior to the inspection by previous Responsible Individual, their replacement has also just left Home Farm Trust. The Commission is awaiting notification of the new Responsible Individual. We inspected fire records and found them to be in good order. The fire plan explains clearly the action staff and people who use the service should take during a fire. Health and safety records are maintained and reflected that necessary safety checks were being conducted e.g. hot water checks to ensure the safety of people who use the service. The service sends out a quality assurance questionnaire to families, people who use the service and to professionals. A report is published and sent out to all participants and reflects what action will be taken. There has been no quality assurance review since the previous inspection but one is planned in the near future. Care Homes for Adults (18-65 years) Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 Care plans should illustrate how decisions are reached and reviewed. There is no way of measuring whether needs have been considered and what level of support may be required e.g. sharing a room. 31/12/2009 2 9 13 Risks must be monitored, managed and met. There must be evidence of how risks are reviewed and measured. Risk assessments must reflect how people are supported or prevented from taking risks under the Deprivation of Liberty aspect of the Mental Capacity Act. 31/12/2009 3 20 13 Medication must be stored appropriately. Storing food and medication together poses a risk of cross contamination and 30/11/2009 Care Homes for Adults (18-65 years) Page 27 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action does not ensure the safety of people who use the service. 4 22 22 A clear and effective complaints procedure must be in place. A record of the complaint, action taken and outcome must be in place to reassure the complainant that the complaints procedure has been followed. 5 23 13 The people who use the service must be protected from abuse and the Safeguarding policy followed. Incidents that place service users at risk of abuse must be reported to the Safeguarding Team in accordance with the local Safeguarding of Vulnerable Adults policy. 6 37 39 The Commission must be 30/11/2009 notified of the return to duty of the registered manager. The arrangements for running the home must be made known to the Care Quality Commission to ensure that the service is safely and competently run. 30/11/2009 30/11/2009 Care Homes for Adults (18-65 years) Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 7 37 37 The Commission must be notified of any issues affecting the wellbeing of people who use the service. The manager must evidence of how people who use the service are adequately protected. 30/11/2009 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 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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