Care Home: Oakmead

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What the care home does well Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Care plans have been produced for all people who use the service, and these inform the care staff what they must do to meet the needs of the individual. One person who uses this service said, "I like living here. Its very good". The staff makes sure that the people who live in the home are safe when they go out and take part in activities. Residents feel they are treated with respect and examples of their dignity and privacy being upheld, were noted during the inspection. The home provides a range of activities to suit people using the service and are tailored to meet their specific likes and preferences. One comment made during this visit was "I like to go to town and I like to buy my papers on a Saturday and a Sunday". Contact with family and friends, is encouraged wherever possible and the home has positive links with the local community via the local church. People using this service are supported to make choices in their daily lives and follow their chosen lifestyle wherever possible. One comment received in a survey was, "I enjoy going on holiday and day trips". The home provides good healthy meals for all the people who live there. Daily routines in the home are flexible and people can choose when they take part in activities. The home provides a pleasant and comfortable environment in which people can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. The people who live in the home, and their friends and family, are supported to make their views known. Staff working in the home have received up to date training. The numbers and skill mix of the staff team meet the current needs of the resident group. Comments received in one staff survey said that Oakmead has a strong friendly workforce that work as a team". There is a robust recruitment procedure in place that ensures service users are protected from harm. On the day of the visit a new care worker was working their first day in the home. They said they had found the organisation to be supportive and they had maintained good communication throughout the recruitment process. The evidence seen and comments received indicate that this service meets the diverse needs e.g. religious, racial, cultural, disability of individuals within the limits of its Statement of Purpose. What has improved since the last inspection? The organisation has reviewed and updated their policies and procedures. On-going improvements to the environment ensure the home remains a safe, homely and clean place to live. What the care home could do better: The home should continue to provide a good quality service to people who use this service and continue with the on-going improvements to the environment. Key inspection report Care homes for adults (18-65 years) Name: Address: Oakmead 19 Worlds End Lane Weston Turville Bucks HP22 5SA     The quality rating for this care home is:   three star excellent 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: Barbara Mulligan     Date: 2 5 0 8 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: Oakmead 19 Worlds End Lane Weston Turville Bucks HP22 5SA 01296615578 N/A michelleread@parkside.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Turnstone Support Ltd care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: The maximum number of service users who can be accommodated is 5. 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: Learning Disability - Code LD Physical Disability - Code PD Date of last inspection Brief description of the care home Oakmead is a small home providing care and accommodation for up to five residents with physical and learning disabilities. The home works with residents to ensure that they are as independent as their abilities enable them to be. The home is in the village of Weston Turville, close to the market towns of Wendover and Aylesbury. Residents use the locally based amenities and are within a short journey of Aylesbury itself. Oakmead is a large detached bungalow, which has five single rooms and communal space situated on the ground floor. There is a dormer area to the bungalow where the office and sleeping-in accommodation for staff is situated. The home has its own vehicle to transport residents and there are ample parking facilities for approximately a Care Homes for Adults (18-65 years) Page 4 of 29 5 5 Over 65 0 0 Brief description of the care home further three vehicles at the front of the property. From the driveway there is easy access into the home and there is an enclosed garden to the rear of the property. The current scale of charges is £1,443.00 to £1505.00. Additional costs are incurred for personal items, travel and holidays. 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: three star excellent 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 unannounced key inspection was conducted over the course of a day and covered all the key National Minimum Standards for Younger Adults. Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) which is completed by the service. This document, which includes information from a variety of sources, was received in good time, was fully completed and contained the information we needed. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document is referred to throughout the report. Information received by the Commission since the last inspection was also taken into account. Surveys were sent to the home for people using the service and for care staff to complete. Nine of these have been received by the Care Quality Commission. The manager of the home was unable to be in attendance for the inspection, however Care Homes for Adults (18-65 years) Page 6 of 29 the service manager for the home assisted with the inspection throughout the day. The information contained in this report was gathered mainly from observation by the inspector, speaking with a number of service users and care staff. Further information was gathered from records kept at the home. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the service manager at the end of the inspection. The management of the home, the staff and service users are thanked for their cooperation and hospitality during this unannounced visit. 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 home should continue to provide a good quality service to people who use this service and continue with the on-going improvements to the environment. 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. People who use the service have their needs thoroughly assessed prior to admission ensuring that staff are prepared for admission, and given opportunity to visit the home beforehand to ensure it can meet their needs. Evidence: The home has an admissions procedure in place which indicates that all prospective service users are assessed prior to admission, that visits take place and that the home liaises with other professionals and families prior to accepting someone for admission to ensure compatibility with the other service users. There have not been any new admissions to the service since the previous inspection, according to information supplied prior to the inspection. At the last inspection, documents relating to the most recently admitted service user were examined and found to be in good order with a detailed and comprehensive needs assessment which indicated that the service user had been involved in the process. The home does not take emergency admissions and does not provide intermediate Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: care. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are very well cared for and this is supported by good record keeping, risk assessments and support from other health care professionals in the community. Evidence: A service user care plan is in place for each person using this service and two of these were examined during this inspection. These are detailed and informative and reflect the changing needs of the individual. Personal and healthcare needs are identified with an action plan setting out guidelines detailing how staff will meet those needs. Individual preferences, likes and dislikes and reference to end of life care are recorded in care plans and describes how these will be met. There is evidence that care plans are reviewed monthly and it is noted that this is a thorough process. Daily notes are detailed and informative and record the personal care received and activities that the individual has undertaken through out the day. Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: One person who uses this service said, I like living here. Its very good. Visual observations of people using this service showed that people were smartly dressed including jewelery, and people were seen to be wearing the aids needed. All individuals have an annual review to which families and interested parties are invited. Monthly residents meetings are held as an open forum. Minutes of these are maintained and were examined during this visit to the home. These show that individuals are encouraged to air their views and be involved in decision making, whether it be about themselves, or choosing a new item for the menu,a new activity or a haircut. In a returned staff survey a comment tells us, the home does well by meeting the needs of service users and their choices are always respected. Annual holidays are discussed and are chosen by the residents. There are holiday plans in place which show how residents make choices and decisions about their holidays. One comment received in a returned survey tells, I enjoy going on holidays and day trips. People using this service are included in the recruitment process and take part in interviewing potential care workers. Records are maintained of these and show that residents have the opportunity to ask questions that are relevant to themselves. Residents continue to be encouraged and supported by staff in making decisions. A local independent advocacy service maintains involvement with the home. Risk assessments have been completed for using the bath with a hoist, using escalators, weight gain, traveling and missing persons. These show that they are reviewed and updated regularly. 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 who use the service have a varied and active lifestyle, which reflects their interests, and are supported to maintain family links and friendships inside and outside the home. Service users receive a balanced diet which meets their nutritional needs. Evidence: Service user files examined outline the individuals interests and activities that they enjoy. There is good regard for the diverse needs of the people living at the home and their requirements related to their disabilities, lifestyle choices and personal preferences. One comment received in a returned survey says, Its brilliant at Oakmead. People who use the service attend activities that are tailored to meet their individual needs. Some of these include walks, shopping in the town, the cinema, bowling and Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: one person attends the local college. Two people have close links with the church and attend church regularly and the church coffee mornings. A comment received in a survey records under the section of what the home does well is support us to go out. On the day of the visit one person was out with a care worker in town having lunch and doing some personal shopping. Some service users continue to regularly attend a social club. When individuals are at home they enjoy a range of interests and on the day of the visit two people were watching their DVD collection together. The service user care plans provides details of what individuals do during the week, social likes and dislikes and information about how they access the community. Family and social contacts were seen recorded in all files. There are no restrictions about family and friends visiting and people who use the service are supported to maintain family relationships and have regular visits from and to their family. One comment received in a returned survey says, I would like to see my friend up the road. From observations on the day of the inspection visit, staff members were seen to treat the People living in the home with respect and patience. One comment made during this visit was I like to go to town and I like to buy my papers on a Saturday and a Sunday. Records are maintained of service users diets and these demonstrate that individual needs, such as healthy eating are being met. Monthly weights are recorded and nutritional screening is evident in files. There is a varied menu and residents contribute to the weekly menu planning. Fresh fruit is available in the home for residents to help themselves when they wish. There was no one requiring special meals on cultural grounds at the time of the inspection. The home will offer drinks and snacks throughout the day in accordance with needs of each individual. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have their needs outlined within their individual plans,ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences. Evidence: Service user care plans provide detailed information about the type of support and assistance people using the service need. We were told that people who use the service are supported to choose when they like to go to bed, have a bath, have their meals and take part in other activities. Choices around clothes and hairstyles remain with the individual and personal preferences are recorded within individual care plans. This was confirmed in a discussion with one person who was in the home on the day of the visit and in surveys returned to the Commission. There is evidence of health care screening in service user care plans. Each file contains a section called information about my health and a health checklist. These contain a record of all healthcare appointments attended by service users. For one individual who has epilepsy there is a detailed support plan in place regarding the management of the individuals epilepsy. Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: There is good information about the support people need with oral hygiene, continence care, personal care and maintaining a healthy weight and nutrition. All service users are registered with a GP practice and specialist services such as physiotherapy, occupational therapy, psychology and speech therapy can be accessed and there is evidence of this recorded in individual files. Medication practices were examined during this visit to the home. There were no individuals who were able to self administer their own medicines at the time of this visit, although there are policies and procedures in place should anyone wish to and be able to do so. Medicines are stored in each service users bedroom, and each room has lockable facilities to store medicines appropriately. Medication Administration Records (MAR) are in good order with staff signatures alongside prescribed dose times. In each care plan there is consent by the service user for staff to administer medicines and a medication risk assessment. There are detailed guidelines in place for the administration of as required/as needed medicines, which are available in the medication administration records. Training records for staff expected to administer medicines were examined and it was noted that staff have completed a care and control of medicines course and they are expected to complete a medication practical assessment every year. 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. The home is able to effectively manage complaints and safeguard service users, ensuring people who use ths service are listened to and kept safe from harm and abuse. Evidence: There is a complaints policy and procedure, which clearly describes the way in which complaints should be handled and the deadlines that are set for response. The complaints procedure is accessible to service users and their representatives and a user-friendly version of the complaints procedure and what abuse is and what to do about it are in the service users guide. A record of all complaints is maintained, and the complaints log was viewed during this inspection. The home has not received any complaints since the last inspection and this information is recorded in the Annual Quality Assurance Assessment (AQAA). People using the service who completed the surveys all said that they knew how to make a complaint. Policies and procedures are in place for safeguarding vulnerable adults (SOVA) and staff have access to a whistle blowing policy. The home has a copy of the local authority safeguarding policy. Training records demonstrate that staff have completed safeguarding training and this is regularly updated. The Annual Quality Assurance Assessment tells us that there have not been any Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: safeguarding referrals in the previous twelve months. 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. A clean, comfortable and homely environment has been created for people who use the service, ensuring that they have appropriate surroundings in which to live. Evidence: Oakmead is a large detached bungalow, which has five single rooms and communal space situated on the ground floor. There is a dormer area to the bungalow where the office and sleeping-in accommodation for staff is situated. The house is clean, well decorated and homely throughout. Thought has been given to the needs of service users throughout the home and each bedroom has been personalised to meet the needs of the person and to reflect their likes and preferences. The kitchen is accessible to service users if they wish to assist with meal preparation. The home provides adequate toilets, shower and bathing areas which are spacious and contain grab rails, assisted baths and other aids. One comment made in a returned survey said I would like better lighting outside and the home should address this The laundry facilities for the home are sited so that soiled washing does not come into Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: contact with the kitchen. Hand washing facilities are sited in the laundry. At the previous inspection it was identifieid that the infection control policies and procedures which had not been updated since July 2002. It was recommended that these are reviewed to ensure that they are in line with new guidance published by the Department of Health. It is pleasing to see that this was completed in June 2007. 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. The staffing numbers and skill mix is satisfactory and staff training is sufficient and up to date to ensure that people who use the service benefit from staff who are competent to do their job. Recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. Evidence: The staff who were met during the inspection were knowledgeable and presented as good advocates for service users. The rotas show adequate numbers of staff are working in the home at any time to meet the needs of the people living in the home. The Annual Quality Assurance Assessment document shows that eight of the ten permanent care staff have completed a National Vocational Qualification level 2 or above. One comment made in a returned survey was Oakmead has a strong friendly workforce that work as a team. The recruitment files for a selection of staff were examined, including those staff new to the service. All files looked at contain the necessary documentation. There is evidence that all staff CRB checks had been obtained and references had been undertaken before the care staff commence employment. On the day of the visit a Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: new care worker was working their first day in the home. They said they had found the organisation to be supportive and they had maintained good communication throughout the recruitment process. All staff complete an induction programme that covers the common induction standards and certificates of completion were observed in the files examined. During the initial induction to the home staff are extra to the numbers on the staff rota and work alongside more experienced staff. Training records show that staff are up to date with their mandatory training which includes moving and handling, fire training, basic food hygiene, infection control, safeguarding vulnerable adults and first aid training. There is specialist training available for staff, and an example of this seen in files includes positive communication, disability and equality, diversity training and autism training. 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. The home is well managed by a stable experienced management team and service users are protected by safe working practices ensuring the health and safety of people using the service. Evidence: The registered manager is Carol Anderson and has been in post since June 2007. She has experience of caring for people with learning difficulties and has registered with the Care Quality Commission. The registered manager has obtained the National Vocational Qualifications (NVQ) in Care at level 4 in Management and Health and Social Care. The organisation and the home has a clear and accountable management structure and the registered manager is supported by the organisation. The inspector noted good teamwork in progress and staff spoken to had a good working knowledge of the individual residents and their care needs. The Annual Quality Assurance Assessment (AQAA) sent out prior to the inspection was returned within the requested timescale and was well completed. The Annual Quality Assurance Assessment (AQAA) informed us of changes the home has made and what areas need to be improved upon. Examples of further training undertaken by the registered manager include safe Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: guarding vulnerable adults, epilepsy awareness, deprivation of liberties and managing absence and capability. The organisations management system includes a quality assurance module which includes sending out satisfaction surveys. These were last sent out to service users between July and September 2007, to relatives in December 2007 and to stakeholders in 2009. The registered manager completes an annual supervised observation exercise for all staff and this is then summarised. This was last completed in June 2008. The registered manager completes monthly monitoring returns and Regulation 26 monitoring visits are undertaken by service managers for the organisation. These follow a detailed format that shows speaking with staff and people who use the service is a regular feature of the visits, plus good practices such as examining a sample of individuals money and staff training records. There are policies and procedures in place to govern the management of the home. At the previous inspection it was identified that the organisations equal opportunities, diversity and anti oppressive policies were dated 2000 and needed to be updated. It is pleasing to see that this has been completed. There is a comprehensive health and safety policy in place and health and safety training is completed and up to date for all staff. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment dated 10/11/2008 and this is reviewed annually. Service reports are in place for PAT testing, gas appliances and electrical installation. 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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