Care Home: Nine Elms Lane

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What the care home does well People have access to relevant information about the service in a format they can understand, so they know what service to expect. The undertaking of a needs assessment ensures people`s needs will be met properly. Staff have access to detailed `Person Centred Plans` so they know how to meet people`s specific needs. People are encouraged to be involved in their care planning, so they receive a service the way they prefer. Written risk assessments promotes people`s independence and ensure their safety whilst doing so. People are provided with the relevant support enabling them to pursue their chosen social interests. Person Centred Plans tell staff how to meet people`s sexuality, cultural and religious needs, so they are able to live a lifestyle of their choice. People are provided with meals that reflect their choice and ensure their nutritional needs are met. Practices and systems in place promote people`s right to privacy. People have access to relevant healthcare services, so their healthcare needs are met. The management of people`s prescribed medicines ensure they receive them regularly and safely. People can be confident their concerns or complaints will be listened to and taken seriously to ensure their rights. Staff are skilled and provided in sufficient numbers to ensure people receive a good service. The cleanliness of the home is of a good standard to ensure people`s health and comfort. Quality assurance monitoring systems ensure people receive a service specific to their needs. What has improved since the last inspection? Medication systems and practices are now more robust to ensure people receive their prescribed medicines safely. People can now be confident there are sufficient staffing levels to met their assessed needs. Chemicals are now securely stored, so people are not placed at risk of harm. What the care home could do better: To ensure the manager submits an application to be registered with the Care Quality Commission, so she complies with the law. Key inspection report Care homes for adults (18-65 years) Name: Address: Nine Elms Lane 87-89 Nine Elms Lane Park Village Wolverhampton West Midlands WV10 9AN     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: Dawn Evans     Date: 2 9 0 3 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) © 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 29 Information about the care home Name of care home: Address: Nine Elms Lane 87-89 Nine Elms Lane Park Village Wolverhampton West Midlands WV10 9AN 01902833730 01902833731 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Name of registered manager (if applicable) Mrs Doreen Ann Lacy Type of registration: Number of places registered: care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Learning disability who may also have physical disability. The maximum number of service users who can be accommodated is: 7 The registered person may provide the following category of service only: Care Home with Nursing (Code N) 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) 7 Physical disability (PD) 7 Date of last inspection Brief description of the care home Nine Elms Lane provides a service for younger adults who have a learning and physical disability and who may require nursing care due to their physical health needs. 1 6 0 6 2 0 0 9 7 7 Over 65 0 0 Care Homes for Adults (18-65 years) Page 4 of 29 Brief description of the care home The home is situated in a residential area and there are a range of community facilities nearby, including shops and pubs. The bus route is within walking distance and the train station is approximately 2.5 miles from the home. There is limited off road car parking to the front of the property. Located on the ground floor are two lounges, separate dining room, kitchen, laundry and toilet. Seven single bedrooms are situated on the first floor. There are no en suite facilities provided but all bedrooms have a washbasin. Situated on the first floor is a shower room and bathroom. Equipment and adaptations are in place which, include passenger lift, raised toilet seat, grab rails, hoist, assisted bath and ramp access to the garden. Staff are available on a 24 hour basis, having a trained nurse on duty at all times. Previous inspection reports are available in the home for people to read if they wish, enabling them to establish the quality of the service and peoples experience of living there. Information about the fees charged for the service was not made available; the reader is advised to contact the home directly for this information. 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 quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out over one day; the home did not know we were going to visit. The focus of inspections we, the Commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, standards of practice and focuses on aspects of service provision that need further development. Prior to the visit taking place we looked at all the information that we have received, or asked for, since the last key inspection. This included notifications received from the home. These are reports about things that have happened in the home that they have Care Homes for Adults (18-65 years) Page 6 of 29 to let us know about by law, and an Annual Quality Assurance Assessment [AQAA]. This is a document that provides information about the home and how they think it meets the needs of people living there. Two people living in the home were case tracked. This involves establishing individuals experiences of living in the care home by meeting them, observing the care they receive, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. We looked around some areas of the home. A sample of care, staff and health and safety records were looked at. Where people who use the service were able to comment on the care they receive their views have been included in this report. Due to the communication needs of people living here, it was not possible to ask the majority of them for their views on the home, so time was spent observing care practices and staff interaction. We sent seven of Have your Say surveys to people who use the service and five to staff members. We received two from people who live there. These were not fully completed. We did not receive any surveys from staff members. We spoke to one person who uses the service and one staff member and their views have been included within this report. Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? Medication systems and practices are now more robust to ensure people receive their prescribed medicines safely. People can now be confident there are sufficient staffing levels to met their assessed Care Homes for Adults (18-65 years) Page 8 of 29 needs. Chemicals are now securely stored, so people are not placed at risk of harm. 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 can be confident they will receive relevant information about the home, so they know what to expect from the service and the undertaking of a needs assessment, should ensure their needs are met on admission. Evidence: People are given a copy of the homes Statement of Purpose and Service User Guide. These documents tell people what they can expect from the service and find out if the home is suitable to meet their needs before making a decision to live there. These documents are published in a written and pictorial format, so people can understand them. The people currently living there were not able to tell us if they had received these documents prior to their admission. The AQAA told us a needs assessment will be undertaken before a person moves into the home. The manager said no one had been admitted to the home since the last inspection visit but confirmed the admission process would include a needs assessment. This assessment should enable the home to establish the persons care needs and the level of support required to meet them. Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: People wishing to use the service are able to visit the home before moving in. This should enable people to find out the homes suitability to 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. People are assured that staff will know how to meet their needs properly and will be supported to live a lifestyle that reflects their choice. Evidence: We case tracked two people and looked at their Person Centred Plan [PCP]. The PCP should tell staff about the persons needs and how to meet them. The PCP provides detailed information about peoples specific care and social needs. For example, it told staff about peoples health condition and the level of assistance required to ensure their health. We also saw in depth information relating to the appropriate methods used to communicate with people; these include verbal, pictures, gestures and Makaton. Makaton is a form of sign language. We spoke to a staff member who was fully aware of information contained within the PCP and they had a clear understanding of the level of support required to meet peoples needs. We also observed care being delivered to people as identified in their Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: PCP. This means people can be confident staff will know how to meet their needs properly. The AQAA shows that people are actively encouraged to be involved in their care planning, and this was confirmed by staff members. The PCP also includes relevant information using photographs, so people can understand it. The PCP tell staff about peoples culture, religion and sexuality, this includes information about dietary needs, skin care, hair care and the way they choose to dress and people important to them. We observed that people were dressed to reflect their choice and preferred style. These practices ensure the service is directed towards peoples personal preferences. We observed that people who use the service have limited verbal communication. However, efforts are made to ensure people are involved in the running of the home. Each person has a keyworker to assist them to make decisions about their live. One to one discussions are undertaken with people, encouraging them to have a say in how the service is delivered. The manager said where necessary people also have access to a self advocacy service. This is an independent service that provides people with additional support enabling them to have a say in how they wish to live their life. We saw risk assessments in place, this tells staff about potential risks and the support people require to reduce these. A discussion with one staff member confirms their knowledge of the support people require to ensure their safety and promote their right to live an independent lifestyle. 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. People are supported to engage in activities of their choice and maintain contact with people important to them, so they are able to live a fulfilled and stimulating lifestyle. Evidence: The AQAA told us three out of four people who use the service attend day care services throughout the week. One persons choice not to attend this service was respected. The PCP shows peoples interests such as walks in the park, shopping trips, going to the cinema, dining out, maintaining contact with family and friends amongst other things. A discussion with a staff member confirms their awareness of peoples social needs and the support they require to engage in these activities. Information contained within the PCP evidenced people are provided with the relevant Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: support to engage in their chosen social interest. This means people can be confident they will be able to live and fulfilled and stimulating lifestyle. The AQAA shows and information contained within the individuals PCP, evidence people are supported to maintain contact with people important to them. Family and friends are able to visit the home. One staff member said We support people to maintain contact with their families. On the day of our visit one person was in the home, three people were attending day care services. We observed staff engaging in activities with this person and assisting them in the kitchen to make a cup of tea. We saw staff communicating with this person in a way they understand and this person appeared to be happy within their environment. Peoples desired form of address is identified on their PCP and we heard staff addressing people appropriately. This shows that peoples right of choice is respected. All bedrooms are single and doors are fitted with a security lock to promote peoples privacy. All bedrooms are unique to peoples specific style and interest in relation to colour, design and equipment. We looked at the homes menus; these show people have a choice of meals to reflect their likes, dislikes and includes meals regarding peoples cultural and health dietary needs. The menus show peoples choice of meals for the day. One person who lives there said, Im having cheesy potatoes for tea, I like that. The food is OK. Where necessary people are supported by a dietician to promote healthy eating. Information about this is contained in the PCP. We spoke to two staff members who had a good knowledge of peoples nutritional needs. 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. People are provided with the support required to ensure their personal needs are met and the appropriate management of their prescribed medicines, ensure they receive their medicines properly. Evidence: We looked at two Person Centred Plans, which contain detailed information about the persons health condition and care needs. The PCP also told staff about relevant equipment needed to assist people with their mobility. A discussion with one member of staff confirms their awareness of the support people need to mobilise safely. During the process of the inspection we also observed staff supporting people in a way as described in the PCP. People can be confident that staff will know who to meet their personal care needs. The AQAA shows and the manager confirms people have access to relevant healthcare services and we saw evidence of this contained within the PCP. These include a General Practitioner, Dentist, Optician and Chiropodist amongst others. People can therefore, be confident they will receive the necessary support to meet their healthcare needs. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: We looked at how the home manages peoples prescribed medicines. We saw that medicines are appropriately stored. The Medication Administration Record [MAR], this is a record that shows peoples prescribed medicines, dosage and when these need to be given. The MAR was signed accordingly to show people are receiving their medicines as recommended by their General Practitioner. This practice also provides an audit trail. People can be assured they will be supported to take their medicines regularly and safely. A written protocol for the safe use of when required medicines is now in place. This protocol tells staff how to administer these medicines properly. When required medicines are prescribed to be given to a person only when needed. For example, medicines for pain relief. 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. People have access to a complaint policy and can be confident their complaint will be listened to and taken seriously so their rights are supported. Evidence: The AQAA shows the home has not received any concerns or complaints since the last inspection visit. The manager also confirms this. Information on how to make a complaint is contained in the homes Statement of Purpose, Service Guide and a separate complaints policy. Most of these documents are accessible to people in written and pictorial format, so everyone can understand them. All past complaints are recorded and show what action was taken to resolve them. The majority of people who use the service have limited verbal communication and are reliant on staff to recognise when they are unhappy and to take the appropriate action. Discussions with one member of staff show their awareness of when people are unhappy. This information is also written in the individuals PCP. People can be assured their concerns or complaint will be listened to and taken seriously to promote their rights. The manager told us the home have not received any safeguarding referrals since the last inspection visit. A safeguarding referral is where there has been an allegation of abuse or where care practices may compromise peoples health or safety. Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: There is a safeguarding policy in place and discussions with staff confirm their awareness of this. This policy tells staff how to recognise various forms of abuse and how to protect people from this. Efforts have now been made to ensure all staff know who to share allegations of abuse with, so people can be confident they will not be placed at further risk of harm. We have not received any complaints or safeguarding referrals about this service. We looked at staff training records, which show staff have received safeguarding training. One staff member also confirms receiving this training. Access to this training should ensure staff have the skills to recognise potential abuse and ensure people are protected from harm. 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. The design and layout of the property is suitable to meet peoples needs but inadequate maintenance of the property may compromise their comfort. Evidence: Nine Elms Lane is situated in a residential area and is easily accessible by public transport. Local shops and park is within walking distance. The property offers seven single bedrooms located on the first floor. Bedrooms are not equipped with en suite but all have a wash basin. A shower room and bathroom is situated near to bedrooms. There is a toilet located on the ground floor. All bedrooms have been personalised to reflect the individuals style and interest. On the ground floor there are two lounges, a separate dining room, kitchen and laundry. People have access to a garden at the rear of the property and this is also accessible for people with reduced mobility. Limited off road car parking is availability at the front of the property. Some areas of the home are tired looking and in need of decorating to ensure the Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: environment is comfortable and stimulating for people live in. Walls and woodwork are in need of painting and we saw holes in the wall of the shower room. The manager also acknowledged this. Equipment and adaptations are in place to promote peoples independence these include a passenger lift, ramp access to the garden and an assisted bath. The standard of hygiene and cleanliness in the home is satisfactory to ensure peoples health. 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. Skilled staff, provided in sufficient numbers ensure peoples needs will be met. Evidence: The home is registered to provide a service for seven people. On the day of our visit four people were living there. The manager said there is currently a surplus of staff to meet peoples needs due to the reduce number of people living there. The means people can be assured there are sufficient staffing levels to meet their needs. On the day of the visit we observed one Registered General Nurse and a Care Assistant on duty to meet the needs of one person in the day and four people in the afternoon. One person is funded an additional five hours per week to assist in meeting their care and social needs. A discussion with the manager confirms there is an adequate staff skill mix to meet peoples needs. These include Registered General Nurses, Registered Learning Disability Nurse and the AQAA shows five out of 13 staff have obtained the National Vocational Qualification Level 2 or above in Care or Social Care. This should ensure staff have the skills to provide an effective service to people who live there. We looked at three staff personnel files; these show that a Criminal Record Bureau Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: [CRB] clearance and Protection of Vulnerable Adults [PoVA 1st] have been undertaken. These safety checks should ensure staff are suitable to work with vulnerable people. We did not see two written references in all the files we looked at. The manager said these are maintained at the head office. The AQAA show staff are encouraged to undertake training, this was confirmed by one staff member. We looked at the staff training records, which show staff have received mental capacity act training, moving and handling, safeguarding amongst others. Access to regular ongoing training should ensure staff have sufficient skills to provide a good service. 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. People can be confident that the home will be managed in a way to ensure their needs will be met and appropriate systems will promote their health and safety. Evidence: The home is run by a manager; the manager confirms she has been in post since June 2009 and has not submitted an application form, to be registered by the Comission. The manager has a legal obligation to do so. A discussion with the manager confirms that she is experienced in health and social care and undertakes regular training. This should ensure she has the skills to manage the home in a way that provides good outcomes for people who live there. A staff member said, The new manager empowers people and staff to be actively involved in the running of the home. We looked at systems in place to promote quality standards within the home. We saw Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: that monthly quality assurance visits are carried out by the area manager. These visits should ensure people receive a service that meets their specific needs The manager said that an annual quality audit is also carried out. This in an in depth inspection that focuses on recommendations and requirements identified within our reports and shows what actions have been taken to address them. Information obtained from this audit are fedback to people, so they know how well their home is being managed and if there are any potential changes to the service. The homes AQAA was sent to us within the required timescale and provides relevant information about the service offered. People are assured that systems in place will ensure they receive a service the way they prefer and promote their independence and rights. The AQAA shows that there are systems in place to ensure peoples health, safety and welfare. Fire fighting equipment are regularly serviced and portable appliance testing are routinely undertaken to ensure equipment are safe. 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 1 37 8 Action must be taken to 31/05/2010 ensure the manager submits an application to be registered with the Care Quality Commission. This will ensure she complies with the Care Standards Act 2000. 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 24 To ensure all areas of the home is suitably decorated, so peoples comfort can be assured. 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. 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