Care Home: Mimosa Lodge

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What the care home does well Peoples needs are known before they move to Mimosa Lodge and so they can be as certain as possible that the service Will be suitable for them. Their care plan is individual and detailed. Information is provided to service users in different forms, for example pictures. This makes it easier to understand and enables service users to make an informed choice. People do a lot of different activities that they have chosen and enjoy. One service user stated in our survey "I have good activities day to day." One member of staff stated "There is a wide range of activities available on a daily basis." Mimosa Lodge is well maintained and provides a clean, comfortable and safe environment to live in. The manager ensures that there are enough staff on duty to make sure that people are offered the right amount of support. Staff know service users well and communicate with them effectively. A lot of staff have worked at the service for a long time and say that they enjoy working with each other and with service users. Comments received in our surveys included "Staff support me in all i do or try to do." and "I like the staff." "Each service user is supported individually according to their needs." Staff are well trained and there are good systems to check them before they work in the home. This helps to keep people safe and ensure staff can meet their needs. Comments included in our surveys stated "Mimosa does its up most to put the needs of service users first." What has improved since the last inspection? Service user care plans have become more "person centered" This means for example that they are asked what their needs wishes and dreams are. Staff have attended Makaton sign language training, this is so that they can communicate more effectively with service users. Service users are encouraged to complete an `are you happy?` checklist once a month with their keyworker. This enables service users to express how they are feeling about the service they are being provided with. The manager stated that there has been a reduction in incidents between service users, which may be as a result of the two previous improvements. What the care home could do better: The manager should make sure the improvements she has identified are carefully planned. This will help to ensure they happen. Key inspection report Care homes for adults (18-65 years) Name: Address: Mimosa Lodge Winchester Road Botley Southampton Hampshire SO32 2DH     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: Tracey Horne     Date: 2 3 0 7 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 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: Mimosa Lodge Winchester Road Botley Southampton Hampshire SO32 2DH 01489789612 01489781691 mimosa@ilg.co.uk winchesterroad@ilg.co.uk Iliace Ltd care home 10 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 10. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home Mimosa Lodge is registered to provide care and accommodation to seven people with learning disabilities. Service users are provided with their own bedroom and share the use of lounge, kitchen, dining room and bathrooms. There is an enclosed garden that service users have access to. An extension is currently being built to provide an additional two bedrooms and separate lounge area. The home is situated in a rural location, approximately a mile from the centre of Botley and next to a pub. The manager reported that the highest fee at the home is #1735.80 per week, but did not have the figures for the lowest fee. Fees are determined by the assessed needs of Care Homes for Adults (18-65 years) Page 4 of 29 Over 65 0 10 Brief description of the care home service users. 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: The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards (NMS) and Regulations. The findings of this report are based on several different sources of evidence. These include: A visit to the home by a Regulatory Inspector. This took place on 23 July 2009 between 10.00 and 15.30. During this time the registered manager, a deputy manager and one relative were involved. The needs of most of residents are such that they are unable to verbally convey their opinions and so time was spent observing interactions between them and staff. Two service users were sent our surveys, two were completed with staff support and were returned. Time was also spent looking at records such as pre admission assessments, Care Homes for Adults (18-65 years) Page 6 of 29 care plans, medication records and staff recruitment and training files. We also looked around communal and some bedrooms. We sent four staff surveys to the service, all were completed and returned to us. An Annual Quality Assurance Assessment (AQAA) was returned to us. The AQAA is a self-assessment that has been completed by the manager. It focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We looked at the previous key inspection report of July 2007 and the most recent Annual service Review of July 2008. We looked at what the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: The manager should make sure the improvements she has identified are carefully planned. This will help to ensure they happen. Care Homes for Adults (18-65 years) Page 8 of 29 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. There are good systems to assess peoples needs before they move into the home. This reassures people that the home will be able to meet their needs. Evidence: The AQAA states that each service user has a support plan which is collated using information gathered from a thorough pre admission assessment with the prospective service user and family members, healthcare professionals and previous history relevant to producing a detailed plan of how the individual wishes to be supported. Each new service user is given an up to date statement of purpose which sets out exactly what the service provide, and includes objectives and terms and conditions. Two service users responded to our survey. They were asked if they wanted to move to the home and got enough information about the home before moving in to help them decide if they wanted to live at Mimosa Lodge. One service user has been admitted since the last key inspection. Records seen showed that the service had obtained a full assessment of need, pre placement observations of the person in their own environment were made by the deputy manager and a detailed two week transition plan which included visits from individual staff, and visits to Mimosa which Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: gave the prospective service user an opportunity to get involved with activities, get to know other service users and staff and stay for meals and overnight and decide how they wanted their bedroom decorated. Once the service user moved in a review was arranged for six weeks time to see if they were happy living at Mimosa Lodge. Service users are encouraged to make choices and decisions on a daily basis from what to eat or do to being involved in planning and redecoration of parts of the home. 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 plans and risk assessments are in place for people so that staff can support them consistently to make choices and take managed risks on a regular basis. Evidence: Three service users care plans were looked at during the visit. Each service user had a care plan that was developed from their initial needs assessment. Since the last inspection the service has developed more person centered plans which include information about peoples likes, dislikes and aspirations and have introduced person centered plan facilitators in order to gain a better insight into how service users are feeling, their hopes and aspirations. The AQAA says that relatives are involved in the care planning and review process. And that service users meet on a monthly basis with their keyworkers to complete are you happy? sheets, that identify any concerns and what actions will be taken to improve things. Records were seen to verified this. Staff surveyed agreed to always being given up to date information about the needs of the people they support. Care plans seen provided information about what service Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: users can do for themselves and specific details about how each person wishes to be supported, for example if they are feeling anxious which may result in displaying certain behaviors. Records showed clear guidelines for staff to follow to minimise the effects of such behaviors which had been devised with the service user, family/advocate and the staff team. Other information included details about service users beliefs and interests such as religion, cultural needs and sexual orientation. And preferred time to wake up/ go to bed and associated routines that enable relaxation prior to going to sleep. Records showed how staff have supported people to realise their wishes, for example for one service user who has expressed a wish to move bedrooms has settled into a room decorated to her taste. Staff on duty were asked if they have any knowledge of the Mental Capacity Act. This legislation is designed to protect people who cannot make decisions for themselves Staff said they did and the manager said that each service users care plan and daily routine is being reviewed to see if any applications are made to the Local Authority for a Deprivation Of Liberty (DoLS) assessment. This is following the DoLS act being implemented this year to ensure that service users are not having any restrictions put on them that are unjust, and that any necessary restrictions are made in the best interest of the service user. Records showed that service users benefit from different types of non verbal communication, the AQAA detailed Makaton sign language, picture board day planners/menu, now and next boards as some examples. Observations made during the visit showed that staff knew how best to communicate with individual service users and intervened appropriately (according to their care plan behavior guidelines) with reassurance when a service user started to become anxious. The AQAA states that all areas of service users lives are appropriately risk assessed to ensure that each individual is supported to take risks with control measures in place. Records show that risk assessments are reviewed regularly and updated where necessary. 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 home provides good support for service users to take part in suitable activities, to maintain relationships with family and friends and provides good food. Service users rights are respected. Evidence: On the day of the visit most service users had decided that morning as it was a nice day theyd like to go to the seaside, which they did in the vehicle the service own. Staff spoken with said that service users go out regularly either in a group or individually. Service user files seen contained records of what activities they liked to do. The AQAA says that each service user has a structured weekly activity schedule that is tailored to their needs and wishes and includes educational and social events, such as dance classes, shopping, day trips out and holidays. Daily routines are varied to suit service users needs and preferences and include in house and community based activities. Staff said they encourage service users to persue their own interests Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: as well as support them to do things that were necessary for their health and wellbeing, for example cooking and cleaning. Service users surveyed stated that they can do what they want to during the day, evenings and weekends. Staff respect their privacy and dignity by treating them well and by knocking on their door before entering their room. The kitchen contains pictorial prompts of various foods and staff explained that these are used with service users to help to plan the weekly menus. staff said that service users go shopping and get involved in preparing, cooking and clearing up after meals. Service user stated in their surveys that the choice of food is very good. We spoke to a relative who visited their daughter at the home. They are very pleased with, feel fully involved in how their daughter is cared for. They said their daughter is very happy living at Mimosa, the staff communicate well, are approachable and make visitors feel welcome whenever they arrive. 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. Individuals health and personal care needs are met and there good systems to safely store and administer peoples medication. Evidence: Details of the personal and healthcare support service users need are set out in their care plans. The AQAA says personal care is always provided in private by person of the same gender. This was confirmed by staff and one service user in their surveys. Records are maintained of service users visits to health services, such as their GP, dentist, optician, speech and language therapist and includes details of any advice given by the practitioner. Medication is stored securely. At the time of this visit no service users are able to manage their own medication and so rely on staff to assist them. The AQAA says that all staff administering medication have undertaken assessed training, which is updated every six months. Records seen verified this. The AQAA also says that the majority of medication is provided in monitoring dosage system (MDS) blister packs. A local pharmacy audit Mimosas medication and processes annually. We spoke to the member of staff who is responsible for ordering and disposing of medicines and completes an in house audit. She confirmed that medication practices have improved greatly, and incidents of medication errors have Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: reduced, and said this may be due to improved training and auditing. 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. Service users are confident their complaints will be taken seriously and acted upon and the home has good adult protection systems, which help to keep service users safe. Evidence: The service has a complaints procedure available, which sets out who will deal with a complaint and how long the provider will take to respond to a complaint. The procedure had been supplied to all service users in an accessible pictorial format. Both service users who responded to our survey stated they know who to speak to if they are not happy, know how to make a complaint and feel that staff listen to them and act upon what they say. The AQAA records that four complaints have been made during the past twelve months and confirmed that all were responded to and resolved within twenty eight days, as the policy states. We looked at the complaints log and one complaint had been received after the AQAA was completed, records showed that the complainant was responded to promptly, the issue has not been resolved yet and meeting has been arranged in October 2009. Staff said that the complaints procedure is discussed with service users as part of the monthly keyworker meetings. The AQAA says that all staff have been issued with local authority and the services guidelines about what to do if they suspect abuse. All staff have received training in adult protection and understand whistle blowing procedures. The service have been informing us of a number of incidents in which challenging behavior had been exhibited by service users, they are required to do this under Care Homes Regulation Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: 37. These had been documented in service users files and reports had been made to Hampshire County Council under safeguarding procedures. The manager said that incidents have reduced recently, and says this may be due to a reduction in staff changes (as any change can be disruptive for some service users which causes them to feel distressed), more person centered care plans that detail trigger and appropriate responses to any behaviors, the provider has developed a behaviors support team to work alongside the staff team to provide structured guidelines that staff were seen to use when one service user became agitated, and staff are getting at recording/tracking events leading to possible behaviors being displayed, as well as recognising new triggers/behaviors. And more ways for service users to communicate, such as sign language, using pictures, healthcare professional support. Care Homes for Adults (18-65 years) Page 20 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. Evidence: The AQAA states that service users are involved in all decisions regarding their home, whether that involves redecoration, refurbishment or plans to improve the garden. This is done formally in reviews, keyworker meetings or informally as part of a conversation. The provider supplies a maintenance team that keep Mimosa in a good state of repair. Staff said they are reliable. We looked around communal areas within the home, all appeared to be well maintained. We looked in three bedrooms, all were individually decorated and furnished, and had personal items in such pictures, furniture and photographs. Staff said that service users are fully involved in choosing the color scheme for their bedrooms. Staff support service users to clean their bedrooms and do their laundry. The staff clean the communal areas. Staff were seen wearing gloves whilst cleaning and cleaning chemicals were stored in a lockable cupboard. The AQAA confirms that all staff complete mandatory training in food hygiene, health and safety and infection control. Monthly health and safety meetings are held to highlight any issues. Both service users surveyed agreed that Mimosa is always clean and fresh. Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: Care Homes for Adults (18-65 years) Page 22 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from being supported by sufficient numbers of well trained staff and are protected by the homes recruitment policies and practices. Evidence: Staff spoken with one the visit demonstrated a good understanding of service users needs. One staff member was able to describe with confidence what signs to look for if a service user with no verbal communication was unhappy or unwell. They also showed a good understanding that challenging behaviors exhibited at times were another way of service users expressing needs preferences and frustrations. The AQAA says that only a quarter of the staff team have completed an NVQ level 2 or above in care or Health and Social Care, but more will be working towards achieving the qualification in the coming months. Staff surveyed said that in general there are enough staff to meet individual needs of all the people who use the service. The AQAA says that Mimosa is almost fully staffed. In the rare occasion agency staff are needed, the service ensures they are familiar to service users to ensure continuity. During the visit there were six staff on duty. The staffing levels reflected what was planned for the day. Staff said that staff meetings take place on a regular basis and there is good communication between them. The AQAA states that Mimosa has a robust recruitment process whereby prospective staff have to apply for an enhanced Criminal Record Bureau (CRB) police check and Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: references are taken up prior to them commencing work. Service users are invited to take part at interviews by asking questions. One staff member said I enjoy my job, we have a good staff team, there is a good working atmosphere. All staff surveyed confirmed that their employer carried out checks such as CRB and references before they started work. We looked at records of the most recently recruited staff members, they contained a recent CRB check, two written references and an induction checklist. Staff surveyed said that their induction covered everything that they needed to know to do the job when they started. All agreed that they are given relevant training which helps them to understand and meet the individual needs of service users and that keeps them up to date with new ways of working. staff spoken with said that training was good and described how they tend to do it in blocks. Records show that training is mandatory in first aid, health and safety moving and handling and food hygiene. Staff said they had training every 6 months in medication management.Records seen confirmed this.Staff also confirmed that they have training in adult protection. Staff surveyed said that the manager meets with them on a regular basis to give support and discuss how they are working, records looked at showed that staff are receiving regular time with their line manager. Care Homes for Adults (18-65 years) Page 24 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. Service users benefit from living in a well-managed home that is safe and responsive to their needs. Evidence: The manager is currently applying for registration with us. The AQAA states that the manager has completed an NVQ 4 and has fifteen years experience in the care sector. The service has a number of systems in place for monitoring their quality, these include surveys that are sent out to all people who use the service, their relatives, staff and other people involved in providing care and support, reviews and meetings. Are you happy? questionnaires for service users to complete, and a comments/suggestions box. Records show that Senior managers from the organisation visit the home each month to review the service quality under the Care Homes regulation 26. Reports of these visits contain actions that are required to improve the service and form the basis of the managers supervision with their line manager. Records showed that risks around the home were assessed and reviewed every six months for example shopping and cooking. The AQAA says that all health and safety certificates are in date. Accidents and incidents to service users and staff Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: are recorded where necessary. Assessments are completed for chemicals used in the home, which are stored in a locked cupboard. Care Homes for Adults (18-65 years) Page 26 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 27 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 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 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). 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