Care Home: Severn Oaks

Similar services:

• 2 Perhaver Park
• The Vicarage
• St George`s
• 5 Seafield Road
• Radfords
• Honeybourne House
• 32 Beaumont Way

What the care home does well People at the home told us about the ways the staff ensured their views are taken seriously and their participation in the planning of their care. They told us they felt safe in the home and that the staff knew how to meet their needs. Staff told us `I feel privileged to work with the individuals here` and staff negotiate and engage with people instead of `nagging` them. What has improved since the last inspection? Staff told us that the team is more dynamic and proactive. They also told us that physical intervention is rare and, diffusion and diversion is used to manage people that express themselves through aggression and violence. Staff feel confident to Whistle Blow and people at the home are confident that they will be safeguarded from abuse. The manager has re-affirmed to the staff what their roles and responsibilities are and re-established systems that have raised the standards of care at the home. What the care home could do better: There are no requirements. Recommendations have been made and they relate to outside agencies signing the management plans to indicate their approval with the way staff can respond to behaviours exhibited. Also to reinforce to staff that they have the skills to manage complex packages of care. Key inspection report Care homes for adults (18-65 years) Name: Address: Severn Oaks 6 Jesmond Road Clevedon North Somerset BS21 7SA     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: Sandra Jones     Date: 1 7 0 2 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 28 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 28 Information about the care home Name of care home: Address: Severn Oaks 6 Jesmond Road Clevedon North Somerset BS21 7SA 01275878447 01275873775 rob.hogan@cintre.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Cintre Community Limited care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: 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 only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection Brief description of the care home Severn Oaks is in a residential area and provides support to younger adults with mild learning disability and complex needs. The home strives to promote independence and acts as a springboard for service users to move toward independent living. It aims to support service users to acquire the whole range of practical skills necessary for living in the community. The home is in a residential area close to the town, sea front and local amenities. 1 4 0 8 2 0 0 9 7 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection was conducted unannounced in over two days in February 2010 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from the staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection including the Annual Quality Assurance Assessment (AQAA) and this information was used to plan the inspection visit. There were four people currently living at the home and three people were case tracked. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people living at the home and other related documents. The homes policies and procedures were also used to confirm the findings. Care Homes for Adults (18-65 years) Page 5 of 28 People at the home were invited to make comments about the standards of care and one person agreed to give feedback. The staff on duty were also consulted and the comments made were used to confirm the documentation. Care Homes for Adults (18-65 years) Page 6 of 28 What the care home does well: What has improved since the last inspection? 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 7 of 28 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 8 of 28 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 wishing to live at the home are reassured through the Statement of Purpose, Service User Guide and Admission process that the home they choose is able and accountable to deliver the services it undertakes to provide. Evidence: There is an updated Statement of Purpose and Service User Guide which is symbolised with pictures and words. It says that the organisations aim is to assist people living in the Cintre organisation to manage their own lives. Within the Statement of Purpose is the Admission procedure which is supplemented by a more detailed procedure. People are informed that assessments will be carried out before their admission and introductory visits are encouraged and trial periods are offered. This will ensure their compatibility with other people already living at the home and the staffs ability to meet the needs of the person. The deputy manager told us that during introductory visits an admission pack whcih included copies of the Statement of Purpose, Service User Guide, house rules and Care Homes for Adults (18-65 years) Page 9 of 28 Evidence: assessments of needs are provided. Pre-Addmission assessments are carried out by the staff and cover physical and mental health needs; social and leisure activities; their independant living abilities and behaviours that may challenge the service. It also states that staff have the skills necessary to respond to people that may express themselves in an aggressive and violent manner. However, the information is brief and needs to be mre detailed about the ethos and the way people are supported to manage their own behaviours. House rules and contracts of residency are clear about the consequences for any breeches and are in formats that can be understood by the people for whom its intended. Contracts describe the arrangements for payment of fees, the management of behaviours that challenge and the expectations of both parties. The fees and room numbers must be added in contracts to ensure people have full information about the homes terms and conditions. Since the last inspection one person tranfered from another home within the organisation. Social workers care plan and pre-admission assessmentswas were conducted with input from an advocate to ensure the move was positive. Care plans and documentation from health and social care professionals confirm that the staff at the home are able to meet the individuals needs. Care Homes for Adults (18-65 years) Page 10 of 28 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. Individuals are at the center of their care and care planning is essential to their delivery of care. People are supported to take control of their own lives and risk are taken safely. Evidence: The manager said that from initial assessments, care plans are developed using a multi-agency approach and input from the person. Care plans describe the background to each area of need with a development plan about the way the need is to be met. Development plans, guidelines, protocols and risk assessments are further developed and signed by the person to show agreement with the action plan. Keyworkers monitor care plans monthly and reviewed six monthly and care management reviews are prepared by the staff in advance of the multi-agency six monthly reviews with the person. We were told that the purpose of the care management reviews is to ensure that the staff attend meetings with up to date information about the persons changing needs. Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: We spoke to the staff about the arrangements in place for meeting the needs of the people at the home. Staff told us that the team either act as keyworkers or cokeyworkers which they say is more positive, staff are more available to specific people. Individuals now have a member of staff on duty that they can go to and receive a definite response about their care. We understood that at the home the role of the keyworker involves engaging and negotiating with people, supporting them with budgeting, discussion with people their daily routines. People at the home can at times exhibit aggressive and violent behaviours to express themselves. The manager told us that training in diffusion and crisis intervention is provided to the staff which ensures that diffusion is used and physical intervention is only used as a last resort. Management plans are in place for people that may exhibit aggressive and violent behaviours. The triggers that may lead to these behaviours are listed along with the strategies to prevent and diffuse escalation. Physical intervention can be used and included is a statement from the person about the way physical intervention can or cannot be used. While there is some evidence that social workers are aware of the management plans in place, their agreements could be included in the management plan. Where there are consequences to certain behaviours, these consequences must be specified. The Responsible Individual told us that physical intervention has reduced since the last inspection, the ethos and training is consistently monitored to ensure good practice guidelines are followed. Comments was sought from staff about the way aggression and violence is managed at the home. One member of staff said that physical intervention was known as control and restraint and was used regularly but physical restraint is rarely used. Staff are now trained in diffusion which has brought about the change in physical intervention and the needs of the people currently accommodated is less complex. Another member of staff confirmed that physical intervention is rare and diffusion and diversion are the techniques used to manage aggression and violence. One person has restriction imposed where time framed 1:1 support is provided to maintain structure and safety and there are structured family visits for another person. People at the home are able to communicate verbally and the manager told us that Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: two people are unable to communicate their needs. The manager told us to ensure that people can make decisions, risk assessments are devised that list the behaviours that indicate the way they make choices. People at the home have an advocate appointed to support them to make independent choices. Risk assessments are in place for all activities that may involve an element of risk. Hazards, triggers and preventative measures are listed with an action plan to reduce the level of risk. They are reviewed monthly by the keyworker and signed by the person which include personal hygiene, self-harm and smoking. Daily reports are compiled on the well-being of he person, staffs observation of the person and outcome of visits from professionals. Care Homes for Adults (18-65 years) Page 13 of 28 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 can take part in activities that are appropriate to their age and culture and are part of their local community. Evidence: Personal Development Plans (PDP) are in place for each person, the manager said that its a practical embodiment of their care plan and depends on the skills and needs of the person. For example, leisure activities and independent skills. PDPs are sectioned into daily living skills, preparing to live independent, training and certificates. However, the progress made is not included within the PDPs. Progress notes about the way the goal is being achieved must be maintained and linked to the care plan. One individual agreed to give feedback about their PDP. This person told us that together with the staff, their care plan was prepared using a picture and word format. We were told that all areas of the care plan were discussed and they agreed with the Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: action plan about the way their care is to be delivered. Opportunities for learning and occupation are available for people living at the home. We were told that people at the home are able to leave the home independently. Where there is a safety risk in the community,the individuals social worker is approached for 1:1 monitoring. Other risks that may hesitate 1:1 support in the community include financial abuse with links to PDPs for budgeting support. Members of staff were consulted about the opportunities for learning and occupation that are available to people. One member of staff told us I am good at engaging with people at the home and we do activities each day. There is a Visitors policy which says that visitors are welcome, where there is a risk and monitoring is necessary a multi-agency protocol is developed. We asked the manager about the way people at the home are respected as individuals. We were told that it begins from the point of assessments, care plans that are tailored around the individual needs with advocate and professionals ensure that peoples rights are respected. For example, Choices of meals, eating together and care packages. People are asked to contribute towards the running of the home because we were told that household chores is part of becoming more independent. There are consequences for not doing chores and people at the home said that organised activities may not happen at the pre-arranged time. The manager said that consequences for not doing household tasks are context based and reflect the level of the breech. Menus are devised during residents meetings, people will give ideas of meals for inclusion on the menu. People have a diet of fresh vegetables with fresh fruit available in the kitchen. A good range of fresh, frozen and tinned food was found and indicates that people have a healthy and varied diet. Care Homes for Adults (18-65 years) Page 15 of 28 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. Personal support is flexible, staff respect individuals preferences and are supported to manage their health care. Evidence: The people at the home are independent with personal care and staff at time prompt people to undertake personal care. Health Action plans are in place for people which includes their personal information, the names of the professional involved in their care, medications prescribed and records of health care visits. A record of visits to GPs and health care specialists is maintained by the staff which show that referrals to specialists are made whenever necessary. One person at present self -administers medication and a safety cabinet was installed in the bedroom. A pictorial record of the individuals competency assessment confirms this individuals ability to self administer their medications. Individuals consulted about medication were able to describe the process that was followed to ascertain their abilities to self-administer their medications. Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: Homely remedies administered from a stock supply when required are not held at the home Care Homes for Adults (18-65 years) Page 17 of 28 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are clear procedures in place and people know how to make their views known and are reassured that action will be taken. People are safe from abuse and benefit from positive behaviour management plans that follow best interest. Evidence: There is a Complaints procedure in place with easy read copies on display in the home. The manager has not received any complaints since the last inspection. The manager told us that the Complaints and Whistle Blowing procedures are permanent agenda items for residents meetings. This will ensure that people know what are steps that will be taken for making complaints. Individuals consulted knew that a complaints procedure was in place and they felt confident to approach staff with concerns. Members of staff giving feedback were clear about the Complaints procedure and the action they must taken. Policies and procedures based on behaviours that challenge are being updated by the Registered Individual. These procedure will reassure Commissioners of placements and people that diffusion and diversion are the ways that aggression and violence are managed. It will ensure that the ethos about the way the staff at the home respond to people that may use aggression and violence to express themselves is part of the Care Homes for Adults (18-65 years) Page 18 of 28 Evidence: procedures. The Safeguarding Adults and Whistle Blowing policies and procedures in place show the organisations commitment to wards safeguarding people from abuse. In terms of the Safeguarding Adults procedure, the contact numbers that must be notified in the event of alleged abuse should be included in the procedure. Comments from one person indicates that they feel safe at the home. We spoke to staff about their responsibilities towards safeguarding people from abuse. One member of staff told us I will whistle Blow and the people here know that I will and they also know that if they break the law I have a responsibility to report it. Another member of staff described an incident where in the past members of staff responded inappropriately to people at the home and this was addressed by introducing mentoring to staff which this member of staff believed was appropriate. Care Homes for Adults (18-65 years) Page 19 of 28 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. Remedial action has been taken to improve the environment for people living at the home Evidence: Severn Oaks is a large period property in a residential area which blends well with its environment, close to shops, amenities and bus routes. Arranged over three floors with communal space on the ground floor and bedrooms on the first and second floor. The personal accommodation is in single bedrooms and with the exception of one all bedrooms are en-suite. On the second floor there are two independent living flats for people that are preparing to live independently in the community. A tour of the property was conducted and it is evident that steps have been taken to address the areas of the home that required attention, in order to provide a homely environment for people living at the home. There is door to the porch and the entrance door was repaired, the foyer of the property was redecorated and floor covering was replaced. The foyer is more welcoming and the people living at the home are more respectful towards their environment. The dining room was converted into a games room which is more useful and people were observed playing snooker with staff. The kitchen is large enough to have a dining table and this is where people now eat their meals. It was evident that vacant rooms are being redecorated, so that Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: people moving into the home have fresh environment for their personal possessions. There is a large lounge at the front of the building with plenty of comfortable seating, and there is a spacious dining room next door to this. The kitchen is big enough to accommodate more seating. Care Homes for Adults (18-65 years) Page 21 of 28 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. People are reassured that staff are skilled to meet their needs and communicate well with them. Also that staffs performance is monitored. Evidence: Since the last inspection, two staff were transfered within the organisation and an inhouse induction took place to ensure their familiarization with the property, housekeeping procedures and the people at the home. Staff that transfered told us that transferring from another home was a struggle but the situation has improved and the team have come together. Another said that since the last inspection all staff have had to re-apply for their posts and successful applicants from two homes were appointed to work at Seven Oaks. Staff said that this team is more dynamic and proactive. Cintre homes has its own training department and the Registered Individual told us that trainers and managers of homes will meet to discuss the way future training needs will be met. It was further stated that the priority is to provide training that ensures staff have the skills to meet the changing needs of people at the home and for managers of homes is budgeting training. Person Centered and managing behaviours that challenge will form part of the training programme for staff. Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: Staff at the home have NVQ level 3 and have attended keyworker; diffusion and physical intervention and Safeguarding Adults training since the last inspection. We discussed supervision with the manager and he said that individual supervision is at least 6 sessions per year. Individuals supervision is usually form line managers and records show that the deputy and manager undertake supervision with the staff. Staff giving feedback said that the training provided was good and addressed all areas of the work at the home. Staff also confirmed that supervision took place and focused on their roles, their performance and training needs. Care Homes for Adults (18-65 years) Page 23 of 28 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 manager is competent and fosters an atmosphere of of openness and respect. The staff at the home fulfill the aims and objectives of the home through policies, procedures and ongoing monitoring of standards. Evidence: Comments about the management of the home were sought from the manager, and we were told that systems were reviewed. We were told that since the last inspection, a review of the admission procedures took place to ensure the range of needs that people have, can be met at the home and new systems were introduced. Systems were re-established and the expectations of the staff was re-affirmed, they know what is expected from them and they must be professional, so that the feeling of safety can be restored. The manager also said that the ethos of inclusion can be verified by the environment and feedback from the people, their Personal Development Plans (PDP) and care plans which confirms that they have a say about the way their care is to be delivered. There is a multi-agency approach to meeting needs and it can be seen by the growth of the people accommodated, people are Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: moving on and becoming more independent. We spoke to staff about the changes that had taken place since the last inspection. We were told that the manager is approachable, they are good role models and the people living at the home react well to the way the home is managed. The Quality Assurance System used by the manager is based on seeking feedback through surveys from people at the home, their relatives and professionals. The information received is then assimilated from the comments and an action plan devised. For example, from the suggestions made from the surveys by the people at the home, the dining room was converted into a games room. Standards of care are monitored by reviewing policies and procedure, report of compliance visits and AQAA. The manager also complies with associated legislation to ensure that people live in a safe environment. Contractors are used to service the boiler system and portable equipment to ensure they functions safely and efficiently. Fire risk assessments are completed to assess the potential of fire in the premises so that preventative measures can be taken to lower the risk. This includes regular testing of fire systems, drills and training of staff. Facilities for the safekeeping of cash and valuables and records show that budgeting is part of the care planning process. The sample records checked corresponded with the balances held in safekeeping. Staffing levels were looked at to ensure that there were sufficient staff on duty to meet the needs of the people accommodated. There are two staff rostered from 7:00 9:00 in the morning which then rise to three staff until 10:00 p.m. when they reduce to two staff that will then sleeping-in. The manager and deputy are supernumerary and managers within the organisation cover the on-call system. Care Homes for Adults (18-65 years) Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 1 4.(1)(a)(b)(c) , 5. (1)(a)(b)(c)(d )(e)(f) Sch. 1 The Statement of Purpose 25/08/2007 and Service Users Guide must include all the required information. Care Homes for Adults (18-65 years) Page 26 of 28 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 1 1 Statement of Purpose should inform people about the way aggressive and violent behaviours are managed in the home. Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!