Care Home: Leahurst

What the care home does well People`s needs are assessed prior to moving into the home. This helps ensure that the home has the facilities to meet the individuals` needs. Systems were in place to help ensure that people receive the medical support they require. People were able to access local amenities independently. People were confident in the homes complaints procedure and knew who to speak to if they were not happy. What has improved since the last inspection? They had added information into the service`s service user guide about the use of CCTV (Close Circuit Television) cameras around the home. However, more information must be included in the service user guide regarding the use of CCTV to help ensure that people are fully aware of the potential impact the cameras may have on their privacy and individual rights. Signage has been put up in the hallway of the home to inform people that CCTV is in use. We saw that they had reviewed and updated how they record assessments of risk for individuals. Food including fruit, cheese, bread, biscuits,chopped ham and corned beef was now available to people when the main kitchen is closed. Monthly visits are now being made to the home by a representative of the provider as part of the quality assurance process. What the care home could do better: To help ensure that people receive the care and support they require, all know risks to individuals must be contained in the person`s care plan. The care plan must demonstrate in detail what action is required to minimise these risk. Meals must be made available at times that people wish. This is to help ensure that people have a flexible lifestyle and a balanced nutritious diet. People must be encouraged through person centered care planning to manage their personal care. Detailed records of all support offered and delivered must be maintained. To help ensure that people have a clean and comfortable environment to live an audit of all decoration, floor covering and furniture must take place and an action plan for refurbishment developed and a copy submitted to the Care Quality Commission. To ensure that the medication policy contains up to date information and guidance for staff it must contain information about the current legislation on the safe storage of controlled drugs. A controlled drugs cabinet compliant with current legislation should be available for the safe storage of this type of medication. Care plans should contain detailed information about what support needs are to be offered and delivered for specific tasks for individuals. To help protect people`s personal information and respect people`s privacy individual records should be maintained for each person. Action should be taken to arrange for the removal of the rubbish at the side of the home. Key inspection report Care homes for adults (18-65 years) Name: Address: Leahurst Coronation Drive Widnes Cheshire WA8 8AZ     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: Adele Berriman     Date: 1 5 0 6 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Leahurst Coronation Drive Widnes Cheshire WA8 8AZ 01514951919 01514233513 HRHLEAHURST@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Hilton Residential Homes Limited Name of registered manager (if applicable) Mr Michael Moran Type of registration: Number of places registered: care home 26 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 26. The registered person may provide the following category of service only: Care home only - Code PC. To service users of the following gender: Either. Whose primary care on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home Leahurst provides personal care for twenty-six adults with enduring mental health needs. The home has two double bedrooms but uses these for single occupancy. There are two buildings, the main building with a first floor independent three bedroom flat and the lodge a three bedroom detached property. The flat and the lodge have their own kitchen, bathroom and living areas. The main building has twenty bedrooms one of which is en-suite. Other facilities include a residents kitchen, dining room, main Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 26 1 8 1 1 2 0 0 9 Brief description of the care home lounge, conservatory and smoking lounge. The home has a patio area to the rear of the property with a large area of lawn, where service users can sit. There is car-parking area at the front of the property. The home is close to local shops and a mile away from Widnes town centre. It is on a local bus route and close to two railway stations. 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: 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: We carried out an unannounced visit to the home on Tuesday 15th June 2010. The visit formed part of a key inspection of the home in which all of the key standards were assessed. Two inspectors visited the home. During our visit we spent time talking to people living at Leahurst, three members of staff, the registered manager and the catering manager. We looked at the communal living areas and a selection of bedrooms. We looked at a selection of records, policies and procedures during the visit, these included care plans, staff files, medication and daily records. Before we visited six people who live at Leahurst and one member of staff completed a survey form to tell us their thought on living and working at Leahurst. Care Homes for Adults (18-65 years) Page 6 of 31 Prior to our visit the manager of the service completed an Annual Quality Assurance Assessment (AQAA). This document gave them the opportunity to tell us what they thought they did well, what they thought they could do better and what improvements they had made over the past 12 months. The AQAA told us most of the information we asked for and also contained some numerical information that we requested. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: To help ensure that people receive the care and support they require, all know risks to individuals must be contained in the persons care plan. The care plan must demonstrate in detail what action is required to minimise these risk. Meals must be made available at times that people wish. This is to help ensure that people have a flexible lifestyle and a balanced nutritious diet. People must be encouraged through person centered care planning to manage their personal care. Detailed records of all support offered and delivered must be maintained. To help ensure that people have a clean and comfortable environment to live an audit of all decoration, floor covering and furniture must take place and an action plan for refurbishment developed and a copy submitted to the Care Quality Commission. To ensure that the medication policy contains up to date information and guidance for staff it must contain information about the current legislation on the safe storage of Care Homes for Adults (18-65 years) Page 8 of 31 controlled drugs. A controlled drugs cabinet compliant with current legislation should be available for the safe storage of this type of medication. Care plans should contain detailed information about what support needs are to be offered and delivered for specific tasks for individuals. To help protect peoples personal information and respect peoples privacy individual records should be maintained for each person. Action should be taken to arrange for the removal of the rubbish at the side of the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 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. People have their needs assessed before they move into the home to ensure that their needs can be met. Evidence: Since we last visited they had reviewed and updated their service user guide and sent a copy to the Care Quality Commission. We saw they had added information to the Service User Guide regarding the use of Close Circuit Television (CCTV) in use around the home. The information stated there are security cameras installed in some areas of the home for your security and the security of the building and there are CCTV cameras in operation within the home but only in some communal areas. More detailed information must be recorded in the Statement of Purpose and Service User Guide to clearly inform people of whether consent to the use of CCTV monitoring is a term and condition of the provision of accommodation and personal care at the home. They told us that prior to a person moving into the home a pre admission assessment was carried out. The purpose of this assessment was to ensure that the staff were aware of peoples individual needs and to ensure that the home had the facilities to Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: meet these needs. The manager told us that he carried out all pre admission assessment for people considering moving into the home. He told us that since we last visited they had revised the pre admission assessment form in which they record peoples needs and wishes. We saw that the pre admission assessment gave the opportunity to record peoples care and health needs within their day to day life. The manager told us that part of the homes pre admission procedure people were invited to visit the home for a meal and maybe an overnight stay prior to moving into the home. No new people had moved into the home since we last visited. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. More detailed and person centered care planning is required to help ensure that peoples needs are fully documented and met. Evidence: We saw that each person had their own file that contained their personal information, pre admission information and their care plan. They told us that since we had last visited they had changed the format of their care plans. We looked at the care plans of three people in detail and saw that they contained some information about peoples day to day needs and wishes. We saw that information written in the care plans was task orientated and not person centered. We saw that not all of the information on the care plans contained clear details of how peoples needs were to be met. For example, one care plan stated that the person needed supervising with a bath but there was no information as to what supervision was actually needed. To help ensure that people receive the support they require care plans should contain detailed information about how support needs to be offered and Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: delivered for specific tasks. Six people living at Leahurst completed a survey form. Three people told is that they can do what they want during the day, the evening and at the weekend and three people told us that they could not. The majority of people who completed a survey form told us that the care staff and manager usually listen and act on what they say. We saw that risk assessments formed part of peoples personal files. These risk assessments considered substance abuse, social circumstances, self neglect, fire and mental state. Not all of the situations identified on risk assessments were included in peoples day to day care plans. For example, we saw a risk assessment for one person that stated that the individual was at risk from choking. The document stated staff to monitor and advise accordingly. No information was available as to how to minimise the risk and the risk was not included in the persons care plan. To help ensure that people needs are met at all times all known risks to an individual must be recorded in the persons care plan and detailed information must be available as to how to minimise the risks. The use of CCTV cameras around the home may limit peoples rights to privacy. The registered provider should ensure that the home is conducted in a manner which respects the privacy and dignity of people. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Person centered care planning would benefit people in accessing more opportunities in their day to day life. Evidence: We saw that an activities plan was available. They told us that staff support people with planned activities including indoor/outdoor games, gardening, board games, giant crosswords, quiz and gardening. We saw no information that demonstrated that people were being encouraged or supported to gain paid or voluntary work within the local community. People told us that they visited the local shops, pub and betting shop on a regular basis and that they were able to leave the home whenever they wished. Two people told us in their survey forms that they could always make decisions about Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: what they do each day, two people told us they usually could and two people told us they sometimes could make decisions about what they did each day. People told us that they were able to choose what time they went to bed and what time they got up and what they wished to wear. One person told us during our visit that they had got up after 8.30am and therefore they had missed their breakfast. To help ensure that people have flexibility throughout their day breakfast should be available to people when they wish. We saw that people had a weekly timetable of activities that formed part of their care plan. We looked at three peoples timetables and saw that no person centered support was identified on the timetables. Information on the timetables related solely to people changing their bed, doing their laundry and having a bath on a weekly basis. Through person centered care planning people should have the opportunity to develop new skills of their choice and be supported in setting personal goals. This will help people develop social and independent living skills. We saw that a four weekly menu was in place and the catering manager told us that the menu changed every four to six months. We saw that meals were served in the dining room with tables set in preparation for the next meal. They told us that breakfast was served from 7am until 8.30am. We asked about the person who had got up after 8.30am and they told us that they could have had some biscuits. They told us that they try to clear breakfast away by 8.30am. To help ensure that people have access to a flexible lifestyle and a nutritious diet meals must be made available at times that people choose. People told us during the visit that they liked the food served at the home. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care needs are not clearly identified or recorded. This may result in people not receiving the care and support they require. Evidence: We saw that each care plan contained a record of health care professional visits which included visits from the GP, dentist, optician and chiropodist along with visits from social workers. Two people who we spoke to during our visit told us that the staff support them when they have health care appointments. They told us in their AQAA that it was intended that a mobile NHS health screening vehicle would visit the home for people to access along with the wider community. We saw that little information was available to demonstrate how and when people required support throughout their day to day life. We saw two situations which demonstrated that people required support with their personal hygiene requirements. They told us in their AQAA that personal hygiene is encouraged but sometimes Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: residents choose not to wash or bathe. We saw no evidence in peoples records as to how and when people are encouraged to wash and bathe. With the lack of records along with our observations we were unable to ascertain whether peoples personal hygiene needs were being met. Individuals must be supported and encouraged by person centered care planning with their personal hygiene and detailed records of all encouragement and support maintained. Failure to support people with their personal hygiene may have a negative effect on the individuals mental and physical wellbeing. We saw that they had a policy for the safe administration of medication. We saw that lockable cabinets were available to keep peoples medication secure. At the time of our visit we saw that there was no storage facility for controlled drugs. In order to comply with current legislation a compliant controlled drugs cupboard must be obtained if someone living at the home is prescribed this type of medication. The current medication policy also needs to be amended to ensure that people are aware of the current legislation around the storage of medication. We saw that all prescribed medication administered was recorded on a Medication Administration Record. We looked at a selection of these records and saw that they were completed appropriately. The senior member of staff who showed us the medication processes within the home demonstrated a good awareness of the safe handing of medication. Care Homes for Adults (18-65 years) Page 18 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People knew who to speak to if they had a concern or wished to make a complaint about the service. Evidence: We saw that a complaints procedure was available around the home. All of the people who completed survey forms and who we spoke to during out visit told us that they knew who to speak to if the were not happy and how to make a complaint. They told us in their AQAA that they had received no complaints about the service within the last 12 months. We saw that a copy of Halton Borough Councils safeguarding procedures were available at the home. We looked a the services policy on abuse and saw that it contained incorrect information as to where all safeguarding referrals need to be made to. To help ensure that staff are able to respond to a safeguarding concern or allegation appropriately; the policy must clearly state that all concerns must be referred to Halton Social Services, the lead agency in safeguarding procedures for Halton Council. Training records demonstrated that three staff had undertaken training in the safeguarding of vulnerable adults since we last visited and the majority of staff had received training in no secrets within the last year. Staff who we spoke to during our Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: visit told us that they would feel confident in raising a concern if required. One safeguarding investigation had taken place since we last visited which was conducted by Halton Social Services. Care Homes for Adults (18-65 years) Page 20 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements need to be made to the decor, floor coverings and furnishings of the home to help ensure that people have a clean and pleasant environment to live in. Evidence: Leahurst is situated on a road close to local bus services, local shops and pub. A car park is available at the front of the building and a large maintained garden with furniture is to the rear. We saw that a walled area to the side of the building contained a large amount of rubbish that could be seen from the road and may become a health and safety hazard. It is recommended that the manager makes arrangements for the rubbish to be removed. We looked at the communal areas around the home which included lounges, toilets, bathrooms and the dining room. We also looked at several peoples bedrooms. Not all areas of the home were found to be clean. For example, we saw several carpets that were badly stained and had a bad odour. We saw that some furnishing were worn, broken and stained and the decor in some areas of the home was dirty and stained. To ensure that people are provided with a clean and comfortable place to live a full audit of the furnishing, decor and floor coverings must be carried out and an action plan of decoration developed. A copy of the action plan must be sent to the Care Quality Commission. Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: We saw that seven CCTV cameras were in use in the hallway and reception area which also has some view of the staff office, the staff room, the laundry, the kitchen, the managers office and the door to the flat. Pictures seen on the CCTV can be viewed from the managers office and the manager and provider whilst they are not in the building. Since we last visited signs had been put up in the hallway of the home to inform people that CCTV is in operation. We saw that the laundry was fully equipped, clean and tidy. Staff told us that residents do their own washing with the support of staff. They told us in their AQAA that they had an action plan to deliver best practice in prevention and control of infection. Care Homes for Adults (18-65 years) Page 22 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. Recruitment procedures in place help protect people living at Leahurst. Evidence: At the time of our visit we saw that three care staff, the manager and the catering manager were on duty to support the needs of the people living at Leahurst. The member of staff who completed a survey form told us that there are usually enough staff to meet the individual needs of the people they support. We looked at the recruitment information on the files of four members of staff. Information on the files demonstrated that appropriate recruitment checks had been carried out prior to the person starting their employment. We saw evidence of Criminal Record Bureau and Protection of Vulnerable Adults checks, completed application forms and written references. They told us in their AQAA that they had a staff development programme that meets the National Minimum Standards. They told us that the service access staff induction training with Halton Borough Council. A training matrix was made available to us that demonstrated that over the past 12 Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: months several staff had attended training in moving and handling, equality and diversity, mental capacity act, no secrets and food hygiene. The training matrix also demonstrated that other training videos made available to staff included abuse in the care home, schizophrenia, anxiety and phobias, depression and infection control. They told us in their AQAA that the majority of staff had completed a National Vocational Qualification (NVQ) level 2 or above for their role. Care Homes for Adults (18-65 years) Page 24 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The overall management of the home remains consistent. However, progress needs to be made with regard to protecting peoples privacy. Evidence: The manager of the home is a qualified nurse with many years experience in working in a social care environment and has been a manager at the home since 1993. The manager told us that the registered provider is in regular telephone contact with the home. Prior to this inspection the manager completed an Annual Quality Assurance Assessment (AQAA). This document gave the service the opportunity to tell us what they do well, what improvements they have made over the last year and and their plans for the next 12 months. The document contained most of the information we asked for and some numerical information we requested. The member of staff who completed the survey form told us that the manager often gives them enough support and meets with them to discuss how they are working. Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: They told us that as part of their monitoring of quality assurance they send out surveys to people on a regular basis to ascertain peoples view on different areas of the home. In addition, a Representative of the registered provider now visits the home on a monthly basis. The manager told us that regular residents meetings take place. Following a requirement made at the previous inspection the manager told us that he had contacted the Information Commissioners office regarding registering the use of the CCTV around the home. The manager said that he had obtained the document to register for the use of CCTV but had not as yet completed it. Under the Data Protection Act 1988 the provider should ensure that the use of CCTV is effectively managed in order to protect peoples privacy. Policies and procedures were in place to support the health, safety and wellbeing of people. They told us in their AQAA that they had up to date test certificate for the homes fire detection system, gas appliances and portable electrical equipment. Care Homes for Adults (18-65 years) Page 26 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 27 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 1 5 The Statement of purpose should clearly inform people whether consent to the use of CCTV monitoring is a term and condition of the provision of accommodation and personal care. This is to help ensure that people are aware of the terms and conditions of the home. 06/09/2010 2 6 13 All known risks to an 06/09/2010 individual must be contained in the persons care plan and detailed information should be available as to what supporting is in place to minimise the risk. This is to help ensure that any identified risks are managed appropriately and that peoples health and wellbeing is not put at any unnecessary risk of harm. Care Homes for Adults (18-65 years) Page 28 of 31 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 3 7 12 The registered provider must ensure that the home is conducted in a manner which respects the privacy and dignity of people. This is to help ensure that that peoples rights to their privacy are upheld.. 06/09/2010 4 17 16 Meals must be made available at times that people choose. This is to help ensure that people have a flexible lifestyle and a nutritious diet. 06/09/2010 5 18 12 A clear plan of what support people require and detailed records of what support has been offered and delivered is required. This is to help ensure that peoples care needs are fully detailed and are being met. 06/09/2010 6 23 13 The services policy on abuse must clearly state that all safeguarding concerns and allegations must be referred directly to Halton Social Services. This is to ensure that staff are aware of who to report concerns and allegations. 06/09/2010 Care Homes for Adults (18-65 years) Page 29 of 31 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 24 23 An audit of all decor, floor 06/09/2010 coverings and furnishing must take place and an action plan for improving the environment developed. A copy of the action plan must be sent to the Care Quality Commission This is to help ensure that improvements are made to peoples living environment. 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 2 3 12 17 20 Person centered care planning should be introduced to support people with setting new life goals and new skills. People should be made aware on a regular basis of what foods are available for supper. The medication policy should be reviewed and updated to ensure that it contained up to date information relating to current legislation around the storage on controlled medication. A controlled drugs cupboard that is compliant with current legislation should be available to store controlled drugs in the event of a person living at the home being prescribed them. The manager should arrange for the removal of the rubbish that is present at the side of the home. The registered provider should ensure that the use of CCTV is effectively managed. 4 20 5 6 24 42 Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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