Care Home: Manor Park Care Home

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What the care home does well Care records provide accurate and up to date information, which means that people receive the level of care and support they require to meet their personal, health and social care needs. There are some people living at the home that enjoy a range of activities and are involved in going out on trips and to day centres. The home also organise trips out shopping and visits to places of interest. Health care professionals said: "Staff cope well with people`s complex needs and there is a caring attitude shown by staff ". Staff have a very good knowledge of people`s health, social and emotional needs. We were impressed with the way in which staff calmly communicated with people even when people became agitated and verbally aggressive. Individually: People`s comments included: "The staff are great ", "I`m happy here ", "Nothing wrong with this place, very good here, staff are first rate ". Staff said they get the training they need to keep them up to date and to help them meet people`s needs. They said they have regular supervision and feel very well supported by the manager. Staff and people spoke very highly of the manager and said she is always available and very approachable. What has improved since the last inspection? Areas of the home are steadily being refurbished which staff and people who live at Victoria Road were pleased to point out to us. People and staff felt that more money was now being spent to refurbish the home. People and staff felt that the amount and type of activities available had certainly improved. Improvements have been made in recruitment procedures to ensure that all the required checks are done before new staff start work. This means people are better protected. Over the last year we can see evidence that the new manager has guided staff at the home to improve standards and makes sure the home is being run in the best interest of the people living there. People have also noted the improvements. They were all in agreement that "Things are now so much better at the home ". The management team of Victoria Road have improved ways in which to check out the quality of the service that they are providing. There is evidence that the ethos of the home is much more open and transparent. Generally the views of both people who use the service and staff are being listened to, and valued. What the care home could do better: Staff and people who use the service must be consulted to highlight any areas of concern over the levels of staff employed. Any shortfalls in staffing levels must be addressed. The work on improving the environment should continue and be completed as soon as possible. This will help to ensure the home is comfortable and suitably furnished to meet people`s needs. Staff should continue to develop and implement individual activity and lifestyle plans with people so that they are supported to achieve their individual goals. It may mean that additional staffing or activity coordinator input should be considered which may benefit people who are less able or willing to join in with activities. Key inspection report Care homes for adults (18-65 years) Name: Address: Manor Court 52 Victoria Road Keighley West Yorkshire BD21 1JB     The quality rating for this care home is:   two star good 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: Mike ONeil     Date: 1 2 0 1 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 29 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 29 Information about the care home Name of care home: Address: Manor Court 52 Victoria Road Keighley West Yorkshire BD21 1JB 01535680410 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr Olu Femiola Name of registered manager (if applicable) Mrs Mary Gbemisola Ashiru Type of registration: Number of places registered: care home 22 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: 22 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 needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD and Code MD(E) Date of last inspection Brief description of the care home Victoria Road Care Home is in Keighley, close to the town centre and local services such as shops and public houses.The home has applied for the name of the service to be changed to Manor Park.We will issue a new certificate with the change of name when the process is complete. The home is easily accessible by public transport, being a short walk from the nearest Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 5 17 3 0 0 1 2 0 0 9 Brief description of the care home bus stop. The home provides accommodation, personal care and support to people with a history of mental illness. Nursing care is not provided and the home will work with district nurses and community psychiatric nurses if this type of support is needed. The main building is a Victorian house that has had extensions added to it over the years. Accommodation is provided in mainly single rooms over two floors. The entrance is up a short flight of steps; people living at the home need to be mobile and able to manage stairs as there are no lifts or facilities for disabled people. There are two lounges, a separate dining room and adequate provision of toilet and bathing facilities. Information about services provided by the home is available in the Service User Guide. Copies can be provided on request. A copy of the most recent inspection is available in the office. The current fees range from 280.00-359.00 pounds per week with additional charges payable for services like hairdressing, chiropody and newspapers. This information was provided at the January 2010 inspection. The home should be contacted directly for up to date information about charges. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection carried out in one day by one inspector. The purpose of this visit was to look at how the needs of people living in the home are being met and to follow up on the requirements made at the last inspection. During the visit we spoke to the majority of people living in the home, all staff on duty and the manager. We looked at various records including care records and looked at some parts of the home. Before the visit we sent surveys to the home to distribute to people using the service, visiting health care professionals and staff. 22 surveys were returned to us and their views are included in this report. We asked the home to complete an Annual Quality Assurance Assessment (AQAA); this is a self assessment which focuses on how the home is meeting the needs of the people using the service. This was completed and Care Homes for Adults (18-65 years) Page 6 of 29 gave us the information we asked for. This report is based on information from our site visit, the feedback from surveys, the homes self assessment, the homes refurbishment plan which was completed by the manager of the home and information we have received about the home since our last visit. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? Areas of the home are steadily being refurbished which staff and people who live at Victoria Road were pleased to point out to us. People and staff felt that more money was now being spent to refurbish the home. People and staff felt that the amount and type of activities available had certainly improved. Improvements have been made in recruitment procedures to ensure that all the required checks are done before new staff start work. This means people are better protected. Over the last year we can see evidence that the new manager has guided staff at the home to improve standards and makes sure the home is being run in the best interest of the people living there. People have also noted the improvements. They were all in agreement that Things are now so much better at the home . The management team of Victoria Road have improved ways in which to check out the quality of the service that they are providing. There is evidence that the ethos of the home is much more open and transparent. Generally the views of both people who use the service and staff are being listened to, and valued. Care Homes for Adults (18-65 years) Page 8 of 29 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 order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 29 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 29 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 are supported in making an informed decision about whether the home is right for them. They can be confident that the home will be able to meet their needs because a full assessment is done before they move in. Evidence: Nine people living in the home completed surveys for us. They said they had been given enough information before moving in to help them decide if it was the right place for them. In the AQAA the service said that people visited the home before making a decision about moving in. One person was currently visiting on a weekly basis. People told us they had visited the home before making a decision about moving in. We saw records of pre-admission assessments in the care plans we looked at. Staff liaised with professionals, the person and their families to find out about peoples needs. This assessment will help to ensure that people have the information needed to Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: make choices about where they live. The home will take emergency admissions, but only if a full needs assessment has been completed and the manager feels that the home can meet their needs. Care Homes for Adults (18-65 years) Page 12 of 29 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. Care records provide accurate and up to date information, which means that people receive the level of care and support they require to meet their personal, health and social care needs. Evidence: The daily records of peoples support were up to date and were generally reflective of the information actually recorded in the persons care/support plan. People told us they are able to make decisions about what they do and how they spend their time. They told us they are supported in maintaining their independence and the records showed that where this involves taking risks there are assessments in place to show how these risks will be managed. People said they often went out into the community with support from staff, chose what they wanted to do during the day and whom they preferred to spend time with. Whenever possible people are supported in managing their own money and this is recorded in the care records. We saw individual records kept of all financial transactions. Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: People told us they are involved in meetings which are held with the manager and staff every month. A meeting was taking place when we arrived at the home. Topics discussed focus on day to day life in the service,menus, and the activities people want to undertake. This type of consultation will help to ensure that people have a say in all aspects of daily life in the service. Care Homes for Adults (18-65 years) Page 14 of 29 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. The service promotes and encourages the development of social and practical skills for some people. This ensures that some people have the opportunity to participate in leisure activities and live as part of the community. People are given the opportunity to exercise their right of choice regarding their daily lives. Evidence: People using the service who completed our surveys and who we spoke with said they are able to make decisions about what they do and how they spend their time. Daily routines are flexible. People said they can have their meals at any reasonable time and we saw people eating their breakfast at varying times during the morning. We found people have been consulted about their interests and what activities and Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: trips they would like to take part in. There is also information about how people like to spend their day. There are some people living at the home that enjoy a range of activities and are involved in going out on trips and to day centres. The home also organises shopping trips and visits to places of interest. A mini bus is available for people to access areas around the county. People were pleased to tell us of all the recent places they had visited and the two holidays they had taken last year. For other people their opportunities for personal development seem to be more limited.Some people said they were bored and just spent the day in the lounge smoking. Health care professionals felt that more meaningful activities were needed for some people. People and staff felt that the amount and type of activities available had certainly improved. However people and staff both felt that additional staffing or activity coordinator input may benefit people and provide more choice and coordination so that more people could attend colleges, work placements or day centres. We spoke with the manager over this issue and she has acknowledged the shortfall in some areas of peoples lifestyle. However she informed us that 3 new care staff and a cook are due to start employment at the home when all the required recruitment checks have been completed. She feels that with positive staff input and the additional staffing resources the educational and leisure needs of all people will be met. People told us they enjoy the food and are offered a choice of meals. As highlighted earlier in this report people are consulted about the menus and changes are made to try to accommodate peoples wishes. Staff are trying to accommodate peoples personal tastes in relation to the food served. We observed the meal service at lunch time. The tables were nicely set, the meal service was well organised and people were given plenty of time to enjoy their food. People told us they had enjoyed their lunch. Care Homes for Adults (18-65 years) Page 16 of 29 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. Peoples health is monitored and arrangements for dealing with health issues are met with support from health professionals. People are treated with respect and said they are very happy with the care they receive. Some medication practices still provide some risk to peoples health and welfare. Evidence: Care plans show that peoples health is monitored and people have access to health care facilities and any relevant specialists that are necessary. Records show that people are assisted and supported by staff to make decisions and choices about all daily living needs. Most of the people living in the home are able to look after their own personal care needs. Some people need staff to encourage and prompt them and we saw some information about this in the care plans. Information of peoples personal care needs is recorded, this also includes peoples wishes and preferences when staff provide personal support in daily routines. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: Health care professionals said: Staff cope well with peoples complex needs and there is a caring attitude shown by staff . Staff have a very good knowledge of peoples health, social and emotional needs. We were impressed with the way in which staff calmly communicated with people even when people became agitated and verbally aggressive. Individually: Peoples comments included: The staff are great , Im happy here , Nothing wrong with this place, very good here, staff are first rate . All medications administered were signed for on peoples medication charts. However people were not fully protected because not all Medicine Administration Records (MAR) were adequate. Some handwritten MAR sheets checked did not contain General Practitioners or two members of staffs signatures alongside any directions regarding the dosage of the medication or the time the medication was to be given. Medication was securely stored in locked cupboards in a locked room. Since our last visit a new metal controlled drugs cabinet has been purchased and secured appropriately to the wall. A risk assessment was in place for one person who manages their own medication. The manager confirmed that risk assessments are carried out for all new admissions and people would be encouraged to manage their own medication if they had the capability. Staff said they had undertaken medication training via a national pharmacy company. Staff said the training was good and this will provide staff with the knowledge to administer medication safely. Care Homes for Adults (18-65 years) Page 18 of 29 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. There are appropriate systems in place to make sure that peoples concerns/complaints are taken seriously and acted on and to make sure that people are protected from abuse. Evidence: Information about the complaints procedure is available in the home. People told us they know how to make a complaint if they need to and know who to speak to if they are unhappy. Staff who completed surveys for us said they know what to do if anyone has a complaint about the service. The home told us they have had one complaint in the last year, no complaints have been referred to us. Records are kept of complaints made and action taken to resolve concerns. Staff said they are aware of protection polices and procedures and said they had received training on safeguarding issues. Records were seen of recent adult safeguarding training staff had undertaken. This ensures people who use the service are safe and protected. Care Homes for Adults (18-65 years) Page 19 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and comfortable but is in need of refurbishment and redecoration to bring the accommodation up to date. Evidence: Refurbishment of the home is required as an ongoing project. Some parts of the home look tired and in need of brightening up. Some paintwork around the home is chipped and some walls damaged. Also the walls around the home are very bare and drab. There is little or no information displayed that may help people with orientation such as calendars or the days food menu. Several corridors were very dark. We were informed that a person living at the home is prone to tour the home turning the lights off. This has created a potential hazard for staff and other people. A risk assessment has been developed to identify the hazard but no action has been taken to address the issue. We discussed with the manager possible solutions to this problem which could include lighting that is movement sensitive or light switches in the corridor areas that cannot be turned off. Significant work however has taken place to improve the environment. This work is continuing. New furniture has been purchased, new carpets fitted and some areas have been redecorated. This refurbishment should continue so that people can live in pleasant surroundings. Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: Systems have been put in place so that dirty laundry can be hygienically moved around the home. People living at the home said that they were generally satisfied with the standard of accommodation, and were pleased that they had been able to furnish their rooms with personal possessions. People living in the home told us the home is always kept clean.The home was clean when we visited. Externally the grounds have been improved old discarded furniture has been cleared and new fencing erected at the front of the home. This has helped to improve the external appearance of the service. Care Homes for Adults (18-65 years) Page 21 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are insufficient staff on duty at some times to support and meet peoples needs. People are protected because all the required checks are done before new staff start work. Staff are supported in developing the skills and knowledge they need to meet peoples needs. Evidence: Staff we spoke with and through surveys felt that sometimes staffing levels are not adequate. Staff said We dont have time to talk to people or do activities and We dont have time to sit and talk to people, we are too busy. People who live at Victoria Road said that staff were usually around when they needed them; they raised no concerns over staffing levels. At the time of our visit the following numbers of staff were on duty: 1 manager, 3 care assistants, 1 cook and 1 domestic. On the day of our visit there were 14 people resident in the home. The Previous duty Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: rotas were checked. These records show that the majority of time similar numbers of care staff were employed within the home although on occasions numbers had dropped to two. Staff said sometimes they also had undertaken catering and domestic duties. The manager confirmed that particularly over the previous week there had been staff shortages due to the deep snow and staff being unable to get to work.The manager said in these instances she and some other staff had tried to cover all the shifts. The manager also informed us that 3 new care staff and a cook are due to start employment at the home when all the required recruitment checks have been completed. In view of the comments made a review of staffing levels must be undertaken. Staff, people who use the service and their representatives must be consulted to highlight any areas of concern over the levels of staff employed. Any shortfalls in staffing levels must be addressed. Every effort should also be made to cover staff absenteeism or sickness so that sufficient numbers of staff are on duty at all times. This will help to ensure that peoples needs can be met. The manager told us that all the required checks are done before new staff start work. Three staff files were checked. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. Staff told us they received induction training when they started work and this covered what they needed to know. Staff said they get the training they need to keep them up to date and to help them meet peoples needs. They said they have regular supervision and feel very well supported by the manager. Comments from staff were generally very positive about the service. They said I really enjoy working here, its much better now. Care Homes for Adults (18-65 years) Page 23 of 29 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. Overall management of the home is good, with policies and procedures in place to protect and safeguard people who use the service. Evidence: Prior to the visit the service had submitted an Annual Quality Assurance Assessment (AQAA). The AQAA was received on time. This shows that the service works in a cooperative manner with us. Since the last key inspection of Victoria Road a new registered manager has been appointed.Mary Ashiru, registered manager has many years experience within the nursing and caring profession and has nearly completed an NVQ level 4 certificate in management of health and social care. We found that the manager was committed to ensuring that people staying at the service were consistently well cared for, safe and happy. Staff and people spoke very highly of the manager and said she is always available and very approachable. Over the last year we can see evidence that the new manager has guided staff at the Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: home to improve standards and make sure the home is being run in the best interest of the people living there. People have also noted the improvements. They were all in agreement that Things are now so much better at the home . The management team of Victoria Road have improved ways in which to check out the quality of the service that they are providing. Regular staff meetings are arranged. Minutes of these meetings were seen. People and their representatives said they saw and spoke with the manager of the home on a regular basis. She always has time to listen one person said. People meet with the manager and staff at a monthly meeting. The meeting was taking place on the day of our visit. The registered provider visits the home on a regular basis, a report is written following the visits and any identified actions taken. People said they saw the registered provider at least every month. There is evidence of internal auditing of the homes environment, services and records. There is evidence that the ethos of the home is much more open and transparent. Generally the views of both people who use the service and staff are being listened to, and valued. The manager and some staff said they have attended training on the Mental Capacity Act and the Deprivation of Liberty legislation. Other staff said they were due to attend training in the next few weeks. Staff generally had a very good understanding of the legislation. Information leaflets are available in the home for people and staff to read. The manager said she is continuing to develop policies surrounding deprivation of liberty. We saw evidence of the policy. The manager said that no one in the home was being deprived of their liberty when we visited. The manager said that the home had previously sought advice from the local social services team. This was because staff were unclear and wanted clarification on whether they were inadvertently depriving a person of their liberty. These systems and staff knowledge will help to ensure that peoples rights are protected and promoted. The self-assessment form completed by the home indicated that the required maintenance and servicing of equipment is up to date or planned to be completed by the end of this month, a sample of records we looked at confirmed this. Staff said they had received recent fire safety and other health and safety training. These measures will promote the safety and welfare of the people. Care Homes for Adults (18-65 years) Page 25 of 29 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 29 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 33 18 An audit of staffing levels 01/04/2010 must be undertaken. Staff and people who use the service must be consulted to highlight any areas of concern over the levels of staff employed. Any shortfalls in staffing levels must be addressed. This will help to ensure that peoples needs can be met. 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 12 Additional staffing or activity coordinator input should be considered which may benefit people who are less able or willing to join in with activities. Staff should continue to develop and implement individual activity and lifestyle plans with people so that people are supported to achieve their individual goals. To protect people the Medication Administration Records (MAR) should contain General Practitioners, or two 2 12 3 20 Care Homes for Adults (18-65 years) Page 27 of 29 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 members of staffs signatures, alongside any directions regarding the dosage of the medication or the time the medication is to be dispensed. 4 5 6 24 24 29 Sufficient and suitable lighting should be provided to make the home safe. The programme of renewal of the fabric and decoration to improve the environment should continue. The environment should be improved to provide more stimulation and provide more information that will help people be orientated to date, time and place. Care Homes for Adults (18-65 years) Page 28 of 29 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 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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