Care Home: St Peters (Flat 1)

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What the care home does well People are provided with a homely living environment so they are comfortable and safe in their surroundings. People are supported by staff who are enthusiastic about their work and understand people`s needs. People are supported to keep in touch with family and friends so they maintain relationships that are important to them. Health and safety is well-managed ensuring peoples safety. Staff receive support and training to do their job and meet peoples needs. People are supported to go on hoildays and take part in activities so they live fulfilled lives. What has improved since the last inspection? Staffing levels have improved a little so there are more opportunities for people to go out. Recruitment practice is now robust so only staff who are suitable to work with vulnerable people are employed. Assessments are in place for the use of bedrails so people are protected. What the care home could do better: Decisions that people make or are made in their best interests should be recorded and the reason why. People`s health care needs should be recorded in full so it is clear that these needs are met. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: St Peters (Flat 1) College Road Saltley Birmingham West Midlands B8 3TF     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: Donna Ahern     Date: 0 7 0 5 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 29 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 29 Information about the care home Name of care home: Address: St Peters (Flat 1) College Road Saltley Birmingham West Midlands B8 3TF 01213284054 01213282867 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Royal Mencap Society Name of registered manager (if applicable) Mrs Dawn Jones Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Residents must be aged under 65 years. Date of last inspection Brief description of the care home Flat 1 St Peters is registered for three adults who have learning disabilities. Mencap are the Registered Providers. The home is situated within a listed building that was once a religious seminary college to train priests. There is level access into the property. The home has three bedrooms and a lounge that is also used as a dining room. Space is very limited throughout the home and doorways are difficult to access for people who use a wheelchair. The bathroom has a specialist bath but again space is very restrictive with no turning room for wheelchairs. The home does not have a private garden area; there are communal grounds that are shared with other properties. We have previously discussed with the providers the Homes lack of fitness for purpose. As a result of these discussions the home had given a commitment to identify Care Homes for Adults (18-65 years) Page 4 of 29 care home 3 Over 65 0 3 Brief description of the care home alternative premises more suited to the needs of people living at St Peters. At the time of this inspection we were informed that referrals have been made to Social Services so people needs can be reassessed. Each of the people living at the Home had a copy of the service users guide and details of fees start from two hundred and sixty nine pounds per week. There is a range of information available on display for visitors to read including a copy of the last inspection report , complaints and safeguarding information and the Homes improvement plan. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. One inspector carried out this inspection over one day; the home did not know we, the commission were going to visit. The previous inspection to this Home took place on 13th May 2008. Three people were living at the home at the time of our visit. We case tracked three peoples care this involves establishing individuals experience of living in the care home Care Homes for Adults (18-65 years) Page 6 of 29 by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. Time was spent observing care practices, interactions and support from staff. Some of the people who live at the home were not able to tell us their views because of their communication needs. One staff member, the assistant manager and manager were spoken to. We looked around some parts of the Home to make sure it was warm, clean and comfortable. We looked at a sample of care, staff and health and safety records. We were sent an Annual Quality Assurance Assessment (AQAA) by the home. This tells us about what the home think they are doing well and where they need to improve. It also gives us some numerical information about staff and people living at the home. We also looked at notifications received from the home. These are reports about things that have happened in the home that the Home must tell us about. 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 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 8 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 9 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. Prospective people and their relatives have the information they need to know so they can make an informed choice about whether they want to live at the home. Evidence: We saw the certificate of registration on display in the hallway. Three people were living there at the time of the visit. People have lived at the Home for many years so it was not possible to assess the pre admission process. We saw that a detailed pre admission procedure is in place and if followed should ensure that full assessments are completed prior to admission. The service user guide and statement of purpose tell people what they can expect from the home and had been written in a style that is easier for the people living there to understand. We saw that the statement of purpose was in the process of being updated to include management and staffing changes. The manager told us they are looking at ways of making documentation more accessible to people and they are exploring putting information onto DVD formats or into what ever format is best for an Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: individual. The Home is not suitable for people who use a wheelchair. The manager requested several months ago that Birmingham Social Services learning disability team completes reassessments of peoples needs. At the time of our visit no progress had been made on this. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have the information they need and a good understanding of how to offer care and support to each person, which should ensure peoples needs are met in a way they prefer. Evidence: We looked at three care plans. Care plans explain what each persons needs are and the care and support they require to make sure these needs are met. We found that the files looked at gave information about how staff should support the person in order to meet their individual needs in relation to personal care, communication, health care, social activities and likes and dislikes. It was positive that pictures and photographs were included throughout the care plan so that they were meaningful and personal to the individual. Information was written in a way that reflected personalised care and included comments such as ask what I want to do first and do things in my own time. If followed this should ensure that people receive support in a way that they prefer. Staff told us how they meet the cultural needs of people including skin care, Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: diet and specific activities. More information about how these needs are met should be in peoples care plans to support the good practice in place. We were told that key workers are supported to develop peoples care plans. We saw a difference in style across care plans and some care plans were more detailed than others. We spoke to two members of staff who support each of the people and we also observed people being supported by staff. The staff demonstrated knowledge of peoples individual needs which was consistent with the information on peoples files. This indicates that staff know how to provide care and support to people so their needs are understood and met. We saw risk assessments for fire safety, support at night, use of wheelchair, bathing and showering. These detail the support people need to be safe whilst still being enabled to be independent. Staff spoken with also knew what they must do so people are not put at risk of harm. We saw staff supporting people to make choices about if they wanted to wear a coat when going out, where they wanted to sit and if they wanted a drink. We looked at daily records for the last few weeks prior to our visit. They do not always reflect peoples response to care, how choices are made and if they are made in the best interest of the individual. Key worker meetings now take place monthly and replace residents meetings. Minutes seen of the outcome of the meetings indicated that information is generally repeated each month and again lacked detail about how or why decisions were arrived at. Consideration should be given to how these meetings can be improved so that decisions people make or are supported to make are clearly recorded. Care Homes for Adults (18-65 years) Page 13 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 live in the Home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs and interests. Evidence: We looked at care plans and daily records to establish that people are leading meaningful lifestyles and taking part in activities that they enjoy. We also spoke to two staff members and observed care and support on the day. Care plans detail what people like to do. Most people attend day centres or colleges from Monday to Friday and have one day a week at Home when they are supported on a 1:1 to do their personal banking, personal shopping or to do an activity of their choice. People were observed in day-to-day tasks such as taking cups and plates to the kitchen, washing up, wiping the tables and generally helping out around the home. Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: We saw staff prompting and encouraging people to do this. Staffing levels had been improved since the last visit which has provided more time for people to be supported to take part in community activities such as going out for meals, walks and doing personal shopping. One of the people is being supported to go swimming, specialist equipment to enable this to happen has been purchased. People seemed relaxed and freely accessed all areas of the home choosing to go to their own bedroom, the kitchen or sitting in the communal lounge. Care plans seen indicated that routines have some flexibility and were individual in how people wanted to be supported indicating that staff try to provide an individualised service. Although when only one staff member is on duty they will have to consider the overall needs and safety of people. Two of the people go to stay with their family each weekend. Staff said they maintain close links and speak regularly to peoples family and recognise the importance of maintaining links with peoples family and friends. A holiday abroad has been planned again for one of the people following the success of previous holiday. Staff said the person would be staying in a hotel with facilities that meet their assessed needs and is accessible throughout. When speaking to the person they indicated that they were looking forward to going. Staff said they are supporting the other two people to make a decision about their holiday arrangements. One of the people will be supported to take a short break and day trips, as this meets their assessed needs best. One of the people really enjoys chat shows and quizzes and staff supported the person to apply for tickets to be in the audience for a live Paul O Grady show in London. This demonstrates that much thought and planning has gone into opportunities for people to ensure they live fulfilled lives. A menu board in the lounge displayed the choice of food for the day using pictures and photographs so people could see what was available. We saw a range of tinned, frozen and supplies of fresh food were available. Menus looked at identified a variety of meals to meet any taste, for example traditional roast meals and spicy dishes. Staff said menus are planned with peoples involvement and pictures are used to help plan the menu. We saw care plans had information about peoples likes and dislikes. On the day of the visit spaghetti bolognaise was being prepared for the evening meal. We saw records of tests in place for food and storage safety checks, these were satisfactory which means food is stored and prepared in a hygienic and safe manner. Care Homes for Adults (18-65 years) Page 15 of 29 Care Homes for Adults (18-65 years) Page 16 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are effective systems in place to meet peoples personal and health care needs. Evidence: Care plans that we looked at had good detail about how to meet peoples personal care needs. There was information about how much support people required from staff and also detailed how people should be encouraged to do as much for themselves in order to maintain their independence. We saw that people were dressed in age appropriate clothing and people were well groomed, this indicates that people are supported to maintain a good self-image. We met all of the people who live in the home and saw that staff were prompt to offer personal care or support as needed. We saw that each person has a Health Action Plan in place these should ensure that individual health care needs are monitored and support needed provided. However we saw that these documents had not been completed in full. Information about specific health care issues such as high blood pressure had only brief information recorded and Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: did not detail in full how staff should support the person to manage the health care need. However we could see from reading recordings of contact with professionals and talking to staff that people were receiving the input they require from health care professionals. We saw that referrals had been made to different professionals such as speech and language, psychology and chiropody so that specific health care needs are met. We looked at the log of health care appointments and saw medical appointments and interventions are recorded so peoples well being can be monitored. My hospital books have been completed in an easy read format. In the event of a hospital stay the books would give nursing staff the information they would need to know about an individual so they receive care in a way they prefer. Bed rail assessments were in place so the rails are only used in the best interest and safety of the person and any risk of entrapments or other injury is minimised. Medication is stored in a locked cabinet in the office. The cupboard was found to be clean, tidy and well ordered. The Medication Administration Records (MAR) had not been signed for on one occasion, but the medication had been given. The manager agreed to follow up on this and review the systems in place for checking MAR sheets at the change over of a shift. Copies of prescriptions are retained so that staff can check the right medication has been received from the chemist. There were no controlled drugs. None of the people self-administered their medication. Peoples consent to medication had been obtained and recorded on their care plan. There is information on peoples care records detailing what the medication is for and possible side effects, which are informative for, staff so they know what to look for. The manager confirmed that staff are assessed annually and receive external training on the safe administration of medication. This should ensure they continue to have the skills and knowledge to administer medication safely. 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. There are effective systems in place to listen to and respond to complaints about the service. Arrangements are in place so people should be protected from harm. Evidence: The complaints procedure is available in an easy read format so it is more meaningful for the people who live at St Peters. However people living at the Home would require considerable support to raise a complaint or concern. We have not recived any complaints about this Home and no complaints have been made directly to the service since our last visit. Staff we spoke to demonstrated a general understanding of their duty to safeguard people and how to report concerns on to senior managers. A local protocol for reporting concerns was on display in the office and needed some updating of contact numbers so people would be able to contact the right department. We looked at training records to determine that training in safeguarding vulnerable adults had been provided. Safeguarding procedures and a whistle blowing policy was available for staff to refer to. Consideration should be given to discussing safeguarding and whistleblowing in staff meetings to ensure that knowledge and understanding in this area is constantly checked. We saw inventories of peoples belongings on their case files. These need some Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: updating, as records looked at had not been completed for over a year. This should ensure that peoples personal items are protected. The AQAA informed us that Mencaps new induction for staff focuses heavily on protection and safeguarding. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean, safe and comfortable home, which promotes their well-being, but does not meet the assessed needs of all the people living there. Evidence: Flat 1 St Peters is a ground floor flat. Previous reports have highlighted that the home does not meet the needs of all the people living there. Space is limited for people who use a wheelchair, as it is difficult to move a wheelchair around. We were informed that the provider has requested that peoples needs are reassessed but Social Services have not yet fulfilled their duty to do this. The bathroom is domestic in layout with limited space for people to move about and is restrictive especially for the people with limited mobility. The manager, whilst waiting on re- assessments of peoples needs, has taken advice from an Occupational Therapist on peoples bathing needs. This has identified a need for a level access shower. Funding for this has been agreed and work should commence soon. The combined lounge dining room has limited space. People are continually moving around each other and the space restricts people who have limited mobility or use a wheelchair. The kitchen leads directly off the lounge area and there is no separate Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: laundry facility. We saw that staff work well with the limited facilities available to them and demonstrated that they understood the need to practice good standards of infection control so that people are not put at risk. Staff told us that people had been supported to personalise their bedrooms. The bedrooms we looked at were very individual. Lamps, cushions, pictures and a variety of lighting had been incorporated to make peoples rooms comfortable, individual and reflective of peoples culture. People freely accessed their own rooms during the visit. 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. Recruitment practice is robust and protects the people who live there. Staff receive the support they need to do their job and meet peoples needs. Evidence: We arrived just after breakfast and we spent some time observing in the lounge . We watched the way that people interacted with staff on duty, which indicated that good relationships exist between people living there and the staff supporting them. We looked at the staffing rota for the week of the visit and the previous week. These showed that there is usually one staff member on duty during the day. On two shifts per week an extra staff member is on duty so that people can go food shopping or take part in planned activities. The manager works mainly 9-5 and provides hands on care when required. On the morning of the visit the staff member was very busy supporting the three people. An incident happened which the staff member managed well, but the safety of other people could have been compromised. We discussed this with the manager who recognised the challenges for staff working in what is mainly a lone working service. She recognised the need to keep staffing levels under review so there is adequate staff on duty at all times to meet peoples needs. Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: We spoke to two staff during this visit who demonstrated that they had a good understanding of peoples individual needs. We spoke to staff about the training they had received and they said that they had completed training in mandatory areas including safeguarding, medication, health and safety, first aid and fire. We looked at the staff training matrix which confirmed mandatory training and training on meeting peoples specific needs had taken place including dysphasia, epilepsy and makaton. This should ensure that staff continue to have the up to date knowledge and skills required to meet peoples individual needs. We looked at staff recruitment records for the two most recently employed people. Criminal Records Bureau checks (CRB) had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the Home with them. Staff told us that they receive regular supervision with the manager. This was confirmed by looking at records and ensures staff have the opportunity to reflect on their practice and consider their individual training needs. Regular staff meetings take place, which provide an opportunity for staff to discuss good practice and development issues. The minutes of meetings seen were very detailed and informative. The AQAA informed us that 5 of the 6 staff have achieved a National Vocational Qualification in care. This should contribute towards ensuring that the staff team have effective knowledge of social care. 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. Arrangements in place ensure the health, safety and well being of people living in the Home. Evidence: The manager has several years experience of working with people who have a learning disability. She has been the manager at St Peters since August 2008 and was recently registered with CQC. She is also the registered manager for Flat 24 St Peters, which is, located in the same complex a short distance from Flat 1. The manager assisted us with the inspection process. She was open and welcoming and demonstrated a commitment to continue to improve standards for people. The requirements we made in the last inspection report had been met which demonstrated a commitment to comply with the regulations. The manager has also pursued the reassessment of people needs with Social Services so peoples current and future needs can be planned for. Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: There are quality assurance systems in place including auditing systems. The homes senior manager carries out monthly visits to the home to monitor and report on standards. Reports are available of these visits. Reports seen were detailed and should ensure that the provider takes responsibility for monitoring the Home. A continuous improvement plan is displayed in the office for people to see. This provides a focus for improving standards across all areas of the Home. People who live in the Home have completed surveys as part of the Homes quality assurance system. The manager told us the format for these will be improved so that they are more meaningful to people. We saw that systems are in place for the recording of accidents and incidents to the commission. Records seen matched what had been reported to us. Staff spoken with and records looked at confirmed that staff have completed training on health and safety, fire, first aid, manual handling and basic food hygiene so a safe environment is provided for people. We looked at some health and safety records including Fire records, gas appliances, safety certificates and water temperatures checks. All are checked and serviced regularly. An independent safety consultant had recently reviewed the work place fire risk assessment, although the report was not yet available in the Home for us to look at. The systems in place that we saw for monitoring health and safety are generally thorough and should ensure peoples health and safety are promoted. The AQAA was received within the required timescale and was completed to a good standard. Information recorded was consistent with our findings. 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 1 2 3 6 7 19 Peoples cultural needs and how these are met should be detailed in their care plan. The decisions people make or are made in their best interest and the reason why, should be clearly documented. Health action plans should be fully completed and health care needs should be planned for, to ensure peoples needs are met in full. The provider should keep us informed with progress on addressing the Homes lack of fitness. Records of peoples belongings should be updated so their personal items are safeguarded. Consideration should be given to discussing the safeguarding and whistleblowing procedures in staff meetings so knowledge and understanding is constantly checked. 4 5 6 23 23 23 Care Homes for Adults (18-65 years) Page 28 of 29 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). 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