Care Home: Spinney Hill Road

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What the care home does well The home is clean and has a homely atmosphere. The people and their families are encouraged to visit the home. One person said that `I loved it` and my family liked it when they visited the home. People who come into this home can be sure that they will be well looked after because the manager makes sure the staff have the right knowledge and training to make sure that they can look after the people properly. The people go on holidays and on day trips with staff which they enjoy. The people are spoken in a respectful and kindly way by staff and when they are being helped with personal care, the staff are careful to make sure it was done in private. The menu in the home is varied and fresh ingrreddients are used when ever possible. One person told us that `I like living here` and `food is nice`. Another person told us `food lovely` and they have `take away food` of their choice and enjoyed this. The bedrooms seen were indivualised to the people and those spoken to tell us `I like my bedroom` and some enjoyed spending time in them. The people like the staff and says `staff helps` me. The staff enjoying working at the home and with the people. One staff says `its great` working at the home and the manager is `supportive` and `very good`. What has improved since the last inspection? One requirement issued at the last inspection was met. What the care home could do better: The home should ensure all staff receives at least 6 supervisions per year to find out how they are working with the people in the home. Provide the service users guide, care planning documents, contracts, complaints procedure in a user friendly format that the people living in the home will be able to understand. Make some of the areas such as the garden and people`s en suite facility pleasant for them to use. Ensure that all the information needed is included in the care planning document to make sure all the needs of the people are met. Review the Service User Guide to ensure all the information stated in the standard is included in the guide so people have all the information about the home. Ensure all staff receives training on safe guarding of vulnerable adults procedures to ensure the people are protected from any harm. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Spinney Hill Road 56 Spinney Hill Road Northampton Northants NN3 6DN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ansuya Chudasama     Date: 2 3 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 33 Information about the care home Name of care home: Address: Spinney Hill Road 56 Spinney Hill Road Northampton Northants NN3 6DN 01604642515 01604642515 manager.spinneyhill@tracscare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Compass Care Ltd care home 3 Number of places (if applicable): Under 65 Over 65 0 0 learning disability mental disorder, excluding learning disability or dementia Additional conditions: 3 3 No person falling within the category of MD, Mental Disorder excluding Learning Disability or Dementia, can be admitted into 56 Spinney Hill Road unless that person also falls within the category of LD, Learning Disability ie Dual Disability. Spinney Hill Road care home is registered to provide personal care to male and female service users who fall within the following categories: Learning Disability (LD) 3. Mental Disorder, excluding learning disability or dementia (MD) 3. The maximum number of persons to be accommodated at Spinney Hill Road care home is 3. Date of last inspection Brief description of the care home The home is registered to provide care for up to three people with a Learning Disability who additionally have a Mental Disorder. The house is on a road of similar houses in a residential area of Northampton. The people are encouraged to be as independent as possible with staff support and supervision. The home is within walking distance of local community amenities, which include shops, pubs and a park. There is a bus service from the estate into town. Accommodation to the people is provided across two Care Homes for Adults (18-65 years) Page 4 of 33 Brief description of the care home floors. All bedrooms are single occupancy, one is on the ground floor with en-suite facilities and two are on the first floor. The ground floor provides a sitting area, kitchen/dinner and conservatory. There is a garden area to the front and rear of the home. The current fees range from 1,800 to 2,137 pounds per week with extra charges for one to one supervision, personal items and persistent wilful damage. The Registered Manager stated that residents and representatives are provided with a service users guide to the services the home offers with the home?s Statement of Purpose and reference to the last Inspection Report. Care Homes for Adults (18-65 years) Page 5 of 33 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 inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies which require review of key standards for the provision of a care home for older people that takes account of the peoples views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. We looked at the Annual Quality Assurance Assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment tool that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Care Homes for Adults (18-65 years) Page 6 of 33 We also looked at the information from the last key inspection and the records of any other visits that we have made to the home in the last 12 months. Information we have about how the home has managed any complaints and things that have happened in the home, which are reported under notifications and are a legal requirement are also looked at. The report refers to we this is because the report is written on behalf of the Quality Care Commission. We last inspected this service on the 25th of June 07. This key inspection was carried out on the 23rd of June 09. The senior support worker helped out with the inspection process. The manager of the home was not working on this day. During this inspection we tracked the care of one person who uses this service. This involved reading their care records and also talking to them to obtain their views on the service provided. We also spoke to all of the other people who live in the home. Documentation relating to staff recruitment, training and supervision, medication administration, complaints and health and safety were also examined. We had the opportunity to talk to some of the staff who were on duty. The Service User Guide states that the current fee is One thousand and eight hundred pounds per week and this is subject to annual review. What the care home does well: What has improved since the last inspection? What they could do better: The home should ensure all staff receives at least 6 supervisions per year to find out how they are working with the people in the home. Provide the service users guide, care planning documents, contracts, complaints procedure in a user friendly format that the people living in the home will be able to understand. Make some of the areas such as the garden and peoples en suite facility pleasant for them to use. Ensure that all the information needed is included in the care planning document to make sure all the needs of the people are met. Review the Service User Guide to ensure all the information stated in the standard is included in the guide so people have all the information about the home. Ensure all staff receives training on safe guarding of vulnerable adults procedures to ensure the people are protected from any harm. Care Homes for Adults (18-65 years) Page 8 of 33 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 set out 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 33 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 33 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. Needs assessments are undertaken for all the people admitted to the home to ensure that their needs will be met. Evidence: The home has a service user guide with some pictures of the home, which is good. However all information stated in the standard needs to be included in the guide. The people spoken to told us that they had visited the home. One person told us that they visited the home and liked it. Another person said that I loved it and my family liked it. The home has not had any new admissions since 2006. The peoples files looked at showed that there were assessment admission details of the person being admitted to the home. All the people in the home have contracts. These are not available in a user friendly format that the people in the home can understand. The peoples representative should also be involved when the people are signing their contract. This is so the people understand their terms and conditions of their stay better. Care Homes for Adults (18-65 years) Page 11 of 33 Evidence: Care Homes for Adults (18-65 years) Page 12 of 33 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people have care planning documents but these needed developing further to include all information stated in the standard to meet their needs. Evidence: We looked at one persons care plan in detail and discussed their care needs with staff on duty. The staff showed that they had very good understanding of the care needs of all the people. Information discussed by staff showed that they were doing lots of work with the people but this was not always recorded in the care plan. Evidence showed that the care plan had been signed by the person. The plan was being reviewed with a date and a signature of staff but the changes were not always being updated on the plan. The people were not being involved in reviewing their care plan. A care plan review sheet dated 14/04/09 was seen but the information recorded was not included in the plan. As discussed at the inspection all the information stated in standard 6 needed to be included in the care plan. This is so the people know how their goals and Care Homes for Adults (18-65 years) Page 13 of 33 Evidence: aspirations are being met by the home. The information in the behaviour support plans was not included in the care plan. The home has not started person centred planning when doing the peoples care plans. There was information on review meetings and one was held on the 24th of February 09. This was positive about the person attending day care workshop. The peoples analysis from the survey carried out in June 08 stated that they make important decisions about their life and feel they are making progress in learning new skills. A range of risk assessments are in place that enables the people to take risks as part of an independent lifestyle. However the information needed expanding and needed to include the five steps to assessing risk as discussed at the inspection. Also some information stated in the risk assessment was not documented in the care plan. The peoples information was kept secure in the office and staff ensured that when they were discussing a persons information, they did this in private. Care Homes for Adults (18-65 years) Page 14 of 33 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. Meals served are nutritious and plentiful with a menu that meets the peoples needs. Evidence: There was information about different routines for day care activity, getting up, having breakfast, lunch, dinner and bedtime in picture format and this was good. The people in the home were observed getting on very well with each other. One person was observed giving another person a hug and this showed the people enjoyed living with each other. We were told that two of the people living in the home had lived in a different home before. We were told and evidence showed that the person being case tracked went to college, the gym, they did gardening, life skills sessions including helping out with cleaning Care Homes for Adults (18-65 years) Page 15 of 33 Evidence: their room. They also helped out with the homes shopping; they went out to social clubs, and also enjoyed going out for walks. The person told us that they like gardening and pigs. As part of the college course they were involved with working with the pigs. We were told that the people visit the other sister homes when they have an activity or visit their friends. The other people in the home also had an active social life which they all enjoyed. All the people had one to one with staff when they went out in the community. The people have a small kitchen where they are able to make drinks and this was observed. We were told that the people choose the menus on a weekly basis and meals cooked are freshly prepared. This was observed. A variety of comments were received about the food that was offered to the people. One person told us that I like living here and food is nice. Another person told us food lovely and that they have take always food and enjoyed this. We observed staff supporting one person when they were having their dinner. This was done in a dignified and kind manner. It was also good to see the person being given time to eat their food. They were observed enjoying their ice cream. The people told us that they liked their bedroom, and each persons bedroom seen was individualised to their taste. Some people enjoyed spending time in their rooms as they preferred this. We were told by the people that they had chosen the colours for their room. This was observed on the day of the inspection. The people like the staff and says staff helps me. They were observed doing their own things and felt very much at home. We were also told that the people go out on day trips and on holidays with staff and one holiday was being booked for September 09. Most of the people in the home maintain contact with their families and friends. Staff takes one person to visit their family every two week, which they enjoy. Care Homes for Adults (18-65 years) Page 16 of 33 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. The peoples health care needs are being met. Evidence: We observed staff interaction and noticed that they talked to people in a respectful manner and were careful to preserve their dignity. One of the people spilled some drink on their clothes and the staff member helped the person put clean clothes in their room by shutting the door. The people we spoke to informed us that the staff knock on their door before entering their room. This was observed on the day of the inspection. Evidence in the care records showed that people are offered support for their physical and emotional health needs. There were records of district nurses, general practitioner, and hospital appointments, and people have access to the opticians, dentists, and other health care professionals. The people told us that if they did not feel well, they would tell the staff. It was also said that staff accompany the people to their appointments. The home had Health Action Plans, which explained the persons Care Homes for Adults (18-65 years) Page 17 of 33 Evidence: health needs in detail. We were told that all the staff who gave out medication had received the accredited training. There were medication profiles for each person. The medication records looked at were being completed properly. The records and medication checked was satisfactory. Care Homes for Adults (18-65 years) Page 18 of 33 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 staff have good understanding of the peoples behaviours to ensure they are protected from any abuse Evidence: The home has a complaints policy, and the procedures for making a complaint is recorded in the Service User Guide. The correct information on CQC needs to be recorded. The home received one complaint and this was dealt with professionally. One staff spoken to told us that they had completed the safe guarding of vulnerable adults procedure training. They had good understanding of this and understood the peoples behaviours to know if they were unhappy or not feeling well. The home has not made any referrals to the safe guarding team of social services. Another person spoken to had not done the safe guarding of vulnerable adults training. However they had good understanding about the peoples needs and know when the people are not happy or not feeling well. It was said that this was by understanding the persons behaviour. The person being case tracked informed us that that they would tell staff if not well and not happy. Another person was able to tell staff if they wanted to make a complaint. One person was not able tell staff verbally if they were unhappy but it was said that the person was able to use sounds and body language signs that the staff Care Homes for Adults (18-65 years) Page 19 of 33 Evidence: had good understanding of, to know if the person was not happy or unwell. The peoples finances were inspected and these were correct and audited well by the organisation. Care Homes for Adults (18-65 years) Page 20 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and has a homely atmosphere but some areas in the home needed attention to make it pleasant for the people in the home. Evidence: A tour of the home showed that the place is clean and homely. There is no smoking in the home. The colour scheme in the home was very pleasant and provided a relaxing atmosphere. This was confirmed by the people and staff spoken to at the inspection. The bedrooms seen were individualised to the people and those spoken to tell us I like my bedroom and some enjoyed spending time in them. One persons bedroom has a toilet and shower cubicle. The person the room belonged to said want bathroom nice, done up. At present the shower and toilet was stained and mouldy and very bad. The flooring was also stained and dirty and smelled. This was discussed with staff on duty who had recently cleaned this area. It was said that no matter how much the place was cleaned, it was difficult to get rid of the stains and mould and smell. This was observed. The persons bedroom had plastic which was frosted was put on their windows because the person pulled their curtains down. However this was torn by the person. We were told that that this was going to be replaced with frosted glass to provide privacy to the person. The floor near the door of Care Homes for Adults (18-65 years) Page 21 of 33 Evidence: the person needed attention because it was split. The laundry and the kitchen with dining room were pleasant, clean and domestic in character. We were told that the home is trying to replace the square table in the dining room with a round table so both staff and the people can sit together. The square table was wobbly and needed attention. The conservatory leading from the dining room was very pleasant and pictures of the people were observed displayed around these areas and made it very homely. The lounge was very pleasant and homely. The lounge, bedroom, and the door leading into the kitchen were kept open sometimes by the people. The people told us that they like to know what is happening in the other rooms and they like to see and hear other people. However these are fire doors. Discussion with the staff in charge stated that they would discuss this with management about having fire guards put on these doors to maintain fire safety. The home has one communal toilet that the people and the staff share. It was said that this can get difficult when a person is having a bath and some one wants to use the toilet. The rear garden outside patio area was not level. The garden needed to be made pleasant for the people to seat out side. The people asked for better furniture for the garden. At present the home has plastic chairs and some looked old and needed cleaning. We were told that the garden was being relayed to make the flooring level. The people were using the front garden to sit in at present. The garden had one side of the area used for growing vegetables and the other side was used as a sitting area. Care Homes for Adults (18-65 years) Page 22 of 33 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 homes recruitment procedures are robust to protect the people from any potential harm. Evidence: The staff recruitment files were looked at in detail. Evidence showed that the relevant checks and references were being obtained when recruiting staff at the home. One staff spoken to stated that they had been at the home for 9 months and said that its great working at the home. They had completed the induction training and said this was good. They had done training on studio three for working with people that have challenging behaviours, first aid, infection control, food hygiene, medication, and health hygiene training. The next training booked was about working as a key worker to the people in the home. It was said that support is good from the manager and she is very friendly. The AQAA states that 3 out of 10 staff have NVQ level 2 or above in care or health. The manager and senior support worker attended the deprivation of liberty training Care Homes for Adults (18-65 years) Page 23 of 33 Evidence: and it was said that this was discussed with the team. Staff say that they were getting supervision but evidence showed that this was not happening six times per year. The home did not use agency staff and we were told that there were enough staff on duty. Staff told us that at present the home was retaining a lot of their staff and this provides continuity to the people. However they did have a high turnover of staff last year. This was also stated by a family member. The staffing rota looked at showed that the manager worked Monday to Fridays. The morning and afternoon shifts consisted of three or two staff being on duty. The home has one night waking staff. We are told that team meetings take place on a monthly basis and they discuss the peoples needs, health and safety information and other issues about the home. Care Homes for Adults (18-65 years) Page 24 of 33 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 acting manager of the home was not available on the day of the inspection. The staff tell us that the manager is very supportive and gives advice. It was also said that she is a good manager and works with the staff. Staff told us we all work on the same lines to meet the peoples needs. The accident and incident records show that these were being recorded appropriately. Records showed that one person had more incidents due to the nature of the persons behaviour. We were told that this was being looked at by health professionals and a chart for recording these incidents was to be started soon. The organisation carries out regulation 26 monitoring visits of the home to find out how the peoples needs are being met. This was well recorded and had an action plan for the manager of the home to follow up. The home undertakes client and staff questionnaire surveys and one was undertaken in June 08. The analysis from the people was very positive about living at the home. For example the people say that they make choices every day and my home is good because of the food and staff. Positive comments from the staff were also received. For example they enjoyed their job because they interact well with the team and the people. There were also areas that the home needed to work on. Care Homes for Adults (18-65 years) Page 25 of 33 Judgement: The home sends in regulation 37 notifications to CQC to inform them of incidents that adversely affect the wellbeing of the people. One referral was made to the safeguarding of social services team but it was said that the incident was not a safe guarding issue. The water temperatures were undertaken and this was satisfactory. Monthly emergency lighting and weekly fire alarm testing was done. There were general risk assessments of the home in a file. Fire drills were undertaken and the people were involved in this procedure. One of the people living in the home had also attended a fire safety course and they were very proud of their certificate. The people carry out safe working practices training to meet the peoples needs. Evidence: The acting manager of the home was not available on the day of the inspection. The staff tell us that the manager is very supportive and gives advice. It was also said that she is a good manager and works with the staff. Staff told us we all work on the same lines to meet the peoples needs. The accident and incident records show that these were being recorded appropriately. Records showed that one person had more incidents due to the nature of the persons behaviour. We were told that this was being looked at by health professionals and a chart for recording these incidents was to be started soon. The organisation carries out regulation 26 monitoring visits of the home to find out how the peoples needs are being met. This was well recorded and had an action plan for the manager of the home to follow up. The home undertakes client and staff questionnaire surveys and one was undertaken in June 08. The analysis from the people was very positive about living at the home. For example the people say that they make choices every day and my home is good because of the food and staff. Positive comments from the staff were also received. For example they enjoyed their job because they interact well with the team and the people. There were also areas that the home needed to work on. The home sends in regulation 37 notifications to CQC to inform them of incidents that adversely affect the wellbeing of the people. One referral was made to the safeguarding of social services team but it was said that the incident was not a safe guarding issue. The water temperatures were undertaken and this was satisfactory. Monthly Care Homes for Adults (18-65 years) Page 26 of 33 Evidence: emergency lighting and weekly fire alarm testing was done. There were general risk assessments of the home in a file. Fire drills were undertaken and the people were involved in this procedure. One of the people living in the home had also attended a fire safety course and they were very proud of their certificate. The people carry out safe working practices training to meet the peoples needs. The acting manager of the home was not available on the day of the inspection. The staff tell us that the manager is very supportive and gives advice. It was also said that she is a good manager and works with the staff. Staff told us we all work on the same lines to meet the peoples needs. The accident and incident records show that these were being recorded appropriately. Records showed that one person had more incidents due to the nature of the persons behaviour. We were told that this was being looked at by health professionals and a chart for recording these incidents was to be started soon. The organisation carries out regulation 26 monitoring visits of the home to find out how the peoples needs are being met. This was well recorded and had an action plan for the manager of the home to follow up. The home undertakes client and staff questionnaire surveys and one was undertaken in June 08. The analysis from the people was very positive about living at the home. For example the people say that they make choices every day and my home is good because of the food and staff. Positive comments from the staff were also received. For example they enjoyed their job because they interact well with the team and the people. There were also areas that the home needed to work on. The home sends in regulation 37 notifications to CQC to inform them of incidents that adversely affect the wellbeing of the people. One referral was made to the safeguarding of social services team but it was said that the incident was not a safe guarding issue. The water temperatures were undertaken and this was satisfactory. Monthly emergency lighting and weekly fire alarm testing was done. There were general risk assessments of the home in a file. Fire drills were undertaken and the people were involved in this procedure. One of the people living in the home had also attended a fire safety course and they were very proud of their certificate. The people carry out safe working practices training to meet the peoples needs. The acting manager of the home was not available on the day of the inspection. The staff tell us that the manager is very supportive and gives advice. It was also said Care Homes for Adults (18-65 years) Page 27 of 33 Evidence: that she is a good manager and works with the staff. Staff told us we all work on the same lines to meet the peoples needs. The accident and incident records show that these were being recorded appropriately. Records showed that one person had more incidents due to the nature of the persons behaviour. We were told that this was being looked at by health professionals and a chart for recording these incidents was to be started soon. The organisation carries out regulation 26 monitoring visits of the home to find out how the peoples needs are being met. This was well recorded and had an action plan for the manager of the home to follow up. The home undertakes client and staff questionnaire surveys and one was undertaken in June 08. The analysis from the people was very positive about living at the home. For example the people say that they make choices every day and my home is good because of the food and staff. Positive comments from the staff were also received. For example they enjoyed their job because they interact well with the team and the people. There were also areas that the home needed to work on. The home sends in regulation 37 notifications to CQC to inform them of incidents that adversely affect the wellbeing of the people. One referral was made to the safeguarding of social services team but it was said that the incident was not a safe guarding issue. The water temperatures were undertaken and this was satisfactory. Monthly emergency lighting and weekly fire alarm testing was done. There were general risk assessments of the home in a file. Fire drills were undertaken and the people were involved in this procedure. One of the people living in the home had also attended a fire safety course and they were very proud of their certificate. The people carry out safe working practices training to meet the peoples needs. The acting manager of the home was not available on the day of the inspection. The staff tell us that the manager is very supportive and gives advice. It was also said that she is a good manager and works with the staff. Staff told us we all work on the same lines to meet the peoples needs. The accident and incident records show that these were being recorded appropriately. Records showed that one person had more incidents due to the nature of the persons behaviour. We were told that this was being looked at by health professionals and a chart for recording these incidents was to be started soon. The organisation carries out regulation 26 monitoring visits of the home to find out how the peoples needs are being met. This was well recorded and had an action plan for the manager of the home to follow up. The home undertakes client and staff questionnaire surveys and one was undertaken in June 08. The analysis from the people was very positive about living at Care Homes for Adults (18-65 years) Page 28 of 33 Evidence: the home. For example the people say that they make choices every day and my home is good because of the food and staff. Positive comments from the staff were also received. For example they enjoyed their job because they interact well with the team and the people. There were also areas that the home needed to work on. The home sends in regulation 37 notifications to CQC to inform them of incidents that adversely affect the wellbeing of the people. One referral was made to the safeguarding of social services team but it was said that the incident was not a safe guarding issue. The water temperatures were undertaken and this was satisfactory. Monthly emergency lighting and weekly fire alarm testing was done. There were general risk assessments of the home in a file. Fire drills were undertaken and the people were involved in this procedure. One of the people living in the home had also attended a fire safety course and they were very proud of their certificate. The people carry out safe working practices training to meet the peoples needs. Care Homes for Adults (18-65 years) Page 29 of 33 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 30 of 33 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 6 15 the care plan must state 25/09/2009 how the persons aspirations and goals will be achieved and describes any restrictions, on choice and freedom and the plan should be reviewed with the person. This is so the people know how the home is helping them achieve theirs goals and aspirations. 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 Review the service userguide to include all the informationstated in the standard. This is so the people have all the information about the home. Review the risk assessments to ensure the five steps to assessing risk are recorded to minise potential risk and hazzards to the people. Ensure all staff receives training on safe guarding of vulnerable adults procedures, autism, mental health, the Page 31 of 33 2 9 3 32 Care Homes for Adults (18-65 years) Mental Capacity Act. 4 32 Ensure the home has over 50 of the staff with NVQ level 2 or above training in care or health to meet the peoples needs Provide staff at least six supervisions per year. 5 36 Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 33 of 33 - 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!