Care Home: The Gables, Stroud

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 admitted to the home are thoroughly assessed before they are offered a place and this minimises the risk of someone being admitted to the home whose needs cannot be met. Care plans cover a wide range of needs and provide a good level of detail that enables staff to meet peoples needs consistently. People have Individual Programme Plans (IPPs) and these provided good evidence of peoples goals being met. There was a wide range of evidence to show that people living in the home are empowered to make choices and staff support them as required. The home has implemented an excellent system to enable people to choose the food they wish to eat and be involved in it`s preparation. People living in the home live active and varied lifestyles supported by staff appropriately. Medication administration is managed effectively and minimises the potential risks to people living in the home. Staff recruitment procedures minimise potential risks to people living in the home. As part of the home`s quality assurance procedures they seek the opinions of other professionals and relatives. Regulation 26 visit are completed monthly and a report is prepared detailing the findings. What has improved since the last inspection? The manager and her team are in the process of implementing care plans in an easy read format to enable people with communication difficulties to understand them more easily. The home`s Statement of Purpose and Service User`s Guide has been updated to include all of the information required by the regulations. Peoples care plans clearly identify goals and provide staff with sufficient detail to enable them to meet peoples needs consistently. The carpet in the hallway of the home has been replaced, and a new lock has been fitted to the toilet door. The home employs staff in sufficient numbers to meet the needs of people in the home.The home has a quality assurance plan. What the care home could do better: The manager needs to ensure that peoples care plans and risk assessments are regularly reviewed to ensure that their current needs are being met and that they are not being put at unnecessary risks. The implementation of the new care plan format has been slow and the manager should ensure that there is an achievable target for when this will be completed. Health care assessments need to be completed to ensure that peoples needs are not missed. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: The Gables, Stroud Lovedays Mead Folly Lane Stroud Glos GL5 1SB     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: Paul Chapman     Date: 2 7 0 7 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: The Gables, Stroud Lovedays Mead Folly Lane Stroud Glos GL5 1SB 01453762229 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) : Stroud & District Mencap Homes Foundation Limited care home 5 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: Date of last inspection Brief description of the care home 5 The Gables is a semi-detached house that provides care and accommodation for five adults with learning disabilities. The home is situated close to the local town of Stroud enabling easy access for community facilities. The home provides twenty-four hour care and is a spacious property with large gardens. The home is staffed and run by Stroud Mencap, which is affiliated to the national Royal Mencap Society but is essentially an independent organisation. The home has a Statement of Purpose and Service User Guide which is available in an additional symbol-based version. The weekly fees to live at the home are vary and are based on an individuals assessed Care Homes for Adults (18-65 years) Page 4 of 33 Brief description of the care home needs. 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: Before completing the inspection site visit to this service we (the CQC) sent the registered manager questionnaires to distribute to people living in the home and for staff to complete. In addition to questionnaires the registered manager also completed an AQAA (Annual Quality Assurance Assessment). This document asks a service provider/registered manager to rate the services performance against the National Minimum Standards (NMS). A service provider/registered manager will be asked to provide evidence of what the service does well, what has improved in the past 12 months and their planned improvements for the next 12 months. What the registered manager tells us in this document helps to form a hypothesis and focus on different areas depending on what the AQAA tells us. In addition to providing evidence about how the home meets the NMS it also provides us with a Dataset (information about Care Homes for Adults (18-65 years) Page 6 of 33 staffing, health and safety, complaints, the environment, policies and procedures and the people living in the home). On the day of our site visit the registered manager was on duty and present throughout the day. We met some of the staff and spoke to 3 individually. We observed the interactions between staff and people in the home and these were seen to be respectful, friendly and empowering. Some people that lived in the home were out completing activities when we arrived while another person was on holiday with their family. We spent sometime with people living in the home and 1 person showed us their holiday photos. We examined the care of 2 people in depth looking at their needs assessments, care plans, how their health needs are met, activities they are involved in and a range of other documents to evidence how staff meet their needs. In addition to this we examined records for staff recruitment, training, policies, procedures and health and safety. What the care home does well: What has improved since the last inspection? The manager and her team are in the process of implementing care plans in an easy read format to enable people with communication difficulties to understand them more easily. The homes Statement of Purpose and Service Users Guide has been updated to include all of the information required by the regulations. Peoples care plans clearly identify goals and provide staff with sufficient detail to enable them to meet peoples needs consistently. The carpet in the hallway of the home has been replaced, and a new lock has been fitted to the toilet door. The home employs staff in sufficient numbers to meet the needs of people in the home. Care Homes for Adults (18-65 years) Page 8 of 33 The home has a quality assurance plan. 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 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. Before anyone is admitted to the home they are thoroughly assessed and this minimises the risk of someone being admitted to the home whose needs cannot be met. Evidence: Since the previous inspection was completed 1 person has moved into the home. Studying the records supporting this process we could see that the manager had completed a comprehensive assessment of the persons needs before they were offered a place. Part of this assessment process included an assessment completed by his funding authority. In addition to these assessments the person was invited to visit the home on a number of occasions, this enabled the person to see the home and for staff to continue their assessment of the person. New tenancy agreements have been introduced using pictures and plain English. The AQAA completed by the manager states that over the next 12 months they will Care Homes for Adults (18-65 years) Page 11 of 33 Evidence: involve people living in the home in reviewing the information pack made available to people who may wish to move into the home. This is seen as good practice. A CQC questionnaire completed by a person living in the home stated, I visited the Gables before I decided whether I wanted to live here, I was able to meet everyone else in the home and was asked what colour I would like my room if I moved in, 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. Care plans have not been reviewed as required and potentially do not reflect peoples current needs. The manager and her staff team empower people in the home to make choices and the service is led by the needs of the people living there. Risk assessments have not been reviewed at regular intervals and this is potentially putting people at unnecessary risks. Evidence: Each of the people living in the home has a range of care plans in place. We studied the care packages for 2 people in detail looking at their assessed needs and the plans to meet those needs. In respect of those people there were care plans to address needs including; personal care, medication, eating and drinking, sleeping and health needs. All of the plans we examined were written to a good level of detail enabling the reader to meet peoples needs consistently. A shortfall with all of the care plans we examined was that they had not been reviewed since October 2008. This was brought to the attention of the manager. They stated that they are in the process of Care Homes for Adults (18-65 years) Page 13 of 33 Evidence: implementing a new format for care planning making use of pictures, we were able to see a completed example of this new format. The example seen was excellent being well written and making use of pictures to enable people with communication difficulties to understand it more easily. The shortfall in reviewing care plans appears to have happened due to the length of time taken to implement the new care plan format. We discussed this with the manager and it was agreed that they needed to have a shorter timescale for when the new format will be introduced. It becomes a requirement of this inspection report that the new care plan format is introduced or the care plans currently in place are reviewed. Staff complete daily notes for each person detailing what they have done and any significant events. At the end of each month these notes are summarised into 1 document for each person. Examining these notes showed that they needed more detail about how peoples care needs were being met. It was difficult for us to see evidence of people care needs being met and any changes to peoples needs. It becomes a recommendation of this inspection report that daily notes also identify what support staff have given people with care plans. Both of the care packages we studied included IPPs (Individual Programme Plan) and there was good evidence of peoples chosen goals being achieved. Throughout the inspection process we found good examples of people being given choices and where required staff supporting them with this. Examples included activities people wished to take part in, holidays booked, the food they ate and how the home was decorated. We spent time with people who lived in the home and this showed staff have respectful and caring relationships with people. Risk assessments were in place for both of the people whose care packages we were examining. Both people had a good range of assessments in place including a range of assessments for a recent summer holiday. When examining the day to day assessments we identified a shortfall in reviewing 1 persons risk assessments. Failure to regularly review a persons risk assessments may mean that they are being put at unnecessary risks. This was brought to the attention of the manager. It becomes a requirement of this inspection report that the manager ensures that all risk assessments are reviewed regularly. The AQAA highlights the shortfalls identified above and states that over the next 12 months the manager will ensure that peoples needs and choices are identified and presented in a format that people can understand. We received a number of comments from staff in questionnaires including, Staff put Care Homes for Adults (18-65 years) Page 14 of 33 Evidence: clients needs first and their needs are always met, people living in the home are happy and confident, the home promotes independence, each person is treated equally. Care Homes for Adults (18-65 years) Page 15 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People lead active and varied lifestyles and staff support them to do this appropriately. Staff empower people to have real choice about the food they eat. Evidence: People who live in the home lead active and varied lifestyles. Some people attend the local day centre, but 3 people have decided they no longer want too. They are taking each day as it comes, the manager explained that enough staff are available to support people with the majority of activities they wish to complete. This was supported by the staffing rota and comments from staff during the site visit. To help people make choices about the activities they would like to complete the home Care Homes for Adults (18-65 years) Page 16 of 33 Evidence: uses pictures and leaflets. Written documents make it difficult for people to understand the choices available. From examining daily notes and speaking to staff there are range of activities that take place regularly with all of the people living in the home, these include; going shopping in the local community and towns surrounding Stroud, visiting the cinema, playing skittles, line dancing, attending a pottery class, going out to local pubs for lunch, art/craft and cooking sessions in house, going out for coffee, horse riding, massage, hydrotherapy and picnics (in good weather). Other occasional activities include visiting the Circus when it was in town, going to Swindon, visiting Birdworld and the Good food show. 2 people decided that they would like to go on holiday to Greece and Rhodes together and staff supported them to do this. To decide where they wanted to go staff supported them to attend the travel agents to pick up brochures. 1 of the people who attended the holiday sat and showed us the photos, staff said they will be supporting them to create a photo album. 2 of the other people living in the home have been to Butlins on holiday and staff are supporting another person in deciding what they would like to do. Parents and family members are welcome at the home and people are supported to maintain contact with them as required. At the time of our site visit 1 person was on holiday with their sister and another person was visited by their father. The choice of food available to people is excellent, the manager and her staff team have developed this since the previous inspection was completed and people have total control over the food they eat. Each week a member of staff meets with each person to create a food shopping list. Each person has a photo album containing pictures of foods/meals and ingredients to help them make choices about what they would like to eat. Some people do not need photo albums as they can tell staff what they want to eat. Sometimes people choose not to create a shopping list and will just choose what they need/want when they are shopping. People dont have a specific shopping day, staff support them with their shopping when they need to go, each person is given £30 a week. On returning from shopping each person labels their food and stores it in their specific cupboard/freezer space. When it comes to meal times each person chooses what they want for tea. This means that 5 different meals could be cooked. In addition to people choosing what they want for their evening meal they chose what they would like for lunch and there is an expectation that they make it themselves. Snacks are available throughout the day. We spoke to the manager about the use of menus and it was agreed that they should just record what food is eaten. Care Homes for Adults (18-65 years) Page 17 of 33 Evidence: When speaking to the manager we discussed house meeting. The AQAA states that over the next 12 months the manager wishes to find a respectful and meaningful method of house meetings that empowers people to have more choice about how they live in the home. A CQC questionnaire completed by a person living in the home stated, I am given choices of what I would like to do each day, if I feel tired I can choose to stay at home and rest, I have a friend who comes to visit me regularly. Care Homes for Adults (18-65 years) Page 18 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. Peoples personal care needs are identified in plans but due to the plans not being reviewed regularly, or recently it is impossible to confirm they accurately reflect peoples needs. Health care assessments have not been completed and it is difficult to easily assess peoples health needs. The homes medication is managed effectively and this minimises potential risks to people. Evidence: The care plans we sampled relating to personal care provided the reader with a good level of detail enabling them to meet peoples needs consistently, unfortunately as with the other care plans we sampled these were also in need of review. The requirement to review care plans identified earlier also relates these care plans. Both of the care packages we studied contained health care assessments completed by a Nurse from peoples Surgery. Further examination of these assessments showed that they had not been completed and a range of areas still required further work, this was brought to the attention of the manager. It becomes a recommendation of this inspection report that staff complete these health care assessments with each person. Care Homes for Adults (18-65 years) Page 19 of 33 Evidence: Each of the files we looked at provided a good record of people having appointments with other medical professionals as required. We examined the homes medication procedures, administration records and storage. This showed that medication is managed effectively minimising potential risks to people living in the home. The manager and her staff team have created end of life plans with people in the home. The manager stated that she feels these documents could be better enabling people to have more choice. It is their plan to review this document. The AQAA states that over the next 12 months the organisation will be looking to develop an action plan to meet peoples needs in relation to their natural ageing process. Care Homes for Adults (18-65 years) Page 20 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 home has a complaints procedure produced in an easy read format to enable people with communication difficulties to understand it more easily. Financial management procedures minimise potential risks to people. Evidence: Speaking with the manager they stated that they have not received any complaints about the home since the previous inspection was completed. The CQC has not received any complaints about the home. The home has a complaints procedure in an easy read format to enable people with communication difficulties to understand it more easily. None of the people currently living in the home are able to manage their monies and therefore this is done by the manager. Only the manager and her deputy have access to monies and records showed that each transaction is signed by both of them. We checked the financial records for 2 people at the time of this site visit and there were correct. The AQAA states that an aim for the next 12 months will be to consider how staff can support people to become more independent managing their finances. A CQC questionnaire completed by a person living in the home stated, If I am Care Homes for Adults (18-65 years) Page 21 of 33 Evidence: unhappy I can speak to any of the staff, I would also speak to the manager. Care Homes for Adults (18-65 years) Page 22 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable, homely and adapted to meet the needs of the people that live there. Evidence: We completed a tour of the premises with staff. We saw all of the communal areas and a selection of the bedrooms. Since the previous inspections site visit was completed a new carpet has been fitted in the homes hallway, the dining area has moved into the conservatory and a new assisted bathroom has been fitted. The walls of the dining room are decorated with the artwork of people living in the home, while the new assisted bathroom has jacuzzi style bath, multi-coloured LED lights and a music system so people can choose what music they listen too. Staff said that the new bathroom is really popular. Looking around the communal areas they were homely, comfortable and decorated to a good standard, personalised with peoples possessions and photos. The only shortfall we identified with the communal areas was the carpet in the dining area was dirty/stained and in need of replacement. This becomes a requirement of this inspection report. Care Homes for Adults (18-65 years) Page 23 of 33 Evidence: The bedrooms we saw were nicely decorated and clearly personalised to the likes and dislikes to the people who lived in them. Specialist adaptations to the home include an assisted bathroom and handrails as required around the home. At the time of this site visit the home was clean and tidy. A CQC questionnaire completed by a person living in the home stated, staff keep to a routine with cleaning and my home is always clean and fresh, I like to clean my bedroom with the support of staff. Care Homes for Adults (18-65 years) Page 24 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 organisations recruitment procedures minimise potential risks to people living in the home. Staff are employed in sufficient numbers to enable people to take part in a range of activities to meet their needs. The organisation provide staff with training to develop their skills and meet the needs of people in the home. Evidence: Since we completed the previous inspection 3 members of staff have been employed. Recruitment records were examined and showed that practices meet the criteria of these regulations and minimise potential risks to people living in the home. Examining the staff rota showed that during the day there are 2 staff on duty per shift. During the night 1 member of staff sleeps in at the home. Speaking with the manager they explained that 1 member of staff has left, while another is starting maternity leave. The manager said that they are addressing this and were due to interview potential candidates on the Friday after this site visit. Speaking with staff during our site visit they agreed that there was a good range of training made available to them. Training records were not seen on this occasion. Care Homes for Adults (18-65 years) Page 25 of 33 Evidence: The AQAA states that the manager wishes staff to complete audits of care plans before appraisals are completed as they will this will enable staff to review their care practice. We received a number of comments from staff in questionnaires including, Management are very supportive and ensure that all training is offered that is relevant to job roles. Care Homes for Adults (18-65 years) Page 26 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. On the whole the home is managed effectively, but the shortfalls around reviewing peoples needs make it difficult for us to confirm that all of peoples needs are being met. There is a clear quality assurance plan and the service is led by the needs of the people living in the home. Health and safety checks completed by the staff team minimise many of the potential risks to people living and working in the home, but the inconsistent monitoring of fire safety equipment puts people at unnecessary risks. Evidence: The manager is registered with the CQC and has been in post at the home for a number of years. They have completed the Registered Managers Award and complete other training for professional development including training in the Mental Capacity Act and the Deprivation of Liberty. We received a number of comments from staff in questionnaires including, The home is a happy place to work. A CQC questionnaire completed by a person living in the home stated, carers listen to me when I speak, my key worker spends 1 to 1 time Care Homes for Adults (18-65 years) Page 27 of 33 Evidence: with regularly. The home has a quality assurance plan in place, through the evidence seen during this site visit the only area that remains outstanding is reviewing the complaints procedure to make it more user friendly. Since the previous site visit the the home has sent surveys to parents, friends and other professionals asking for their opinion of the service at the home. The results we saw were very positive and the manager had feedback to the staff team what had been said. We see the use of questionnaires to other parties involved in the home as good practice. The only recommendation that we would make is that the manager could collate the information into a report identifying the findings and actions required to address shortfalls. Under Regulation 26 of these regulations monthly unannounced visits should be completed by the responsible individual (see NB*). At the site visit we saw reports for visits completed in December 2008, April and June 2009. The manager was unaware of any other visits/reports being completed. After this inspection the organisations genral manager provided us with evidence of visits being completed monthly. It becomes a recommendation that the general manager ensures that the homes manager is aware of these visits and their subsequent reports. The organisation provide a wide range of policies and procedures that meet the criteria of these regulations. It is planned that these policies and procedures will be made more user friendly by making use of pictures and plain English. The health and safety of staff and people in the home is taken seriously and there were a wide range of measures taken to minimise potential risks. Evidence of this was seen in the records kept in the home and from speaking with staff: - Appropriate staff training records we in place. Risk Assessments for the homes environment are in the process of being reviewed. The temperature of hot water outlets is tested monthly. Fridge and freezer temperatures are tested and recorded daily. PAT (Portable Appliance Testing) was being completed in the same week as this site visit. Fire safety checks - Records showed the alarm and lights are not being completed regularly this must be addressed. An Evacuation has been completed recently. The fire systems have been serviced as required. The home has a fire risk assessment in place but it must be reviewed. In the AQAA the manager states they must ensure they keep up to date with making sure documents are reviewed regularly as required. NB - Under Regulation 26 of the Care Homes Regulations (2001) where a Responsible Individual is not in day to day charge of the home a monthly unannounced visit to the home must be completed by them or their representative and a report of those findings must be available for the CQC. Care Homes for Adults (18-65 years) Page 28 of 33 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 manager must ensure 28/08/2009 that all of the care plans in the new format are implemented without delay, or they must review the care plans in place presently. Current care plans have not been reviewed at regular intervals and it is impossible to confirm that they reflect peoples current needs. 2 9 13 The manager must ensure 28/08/2009 that all risk assessments are reviewed at regular intervals to ensure that they accurately reflect the potential risks present. Failure to complete regular reviews of risk assessments may put people at unnecessary potential risks. 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 Care Homes for Adults (18-65 years) Page 31 of 33 improving their service. No. Refer to Standard Good Practice Recommendations 1 6 Staff should ensure that daily notes include more detail relating to meeting peoples needs identified in their care plans. This would help when reviewing care plans. The manager should ensure that all of the healthcare assessments are completed thoroughly. The manager should compile a report into the findings of their quality assurance procedures. The manager should ensure that they are aware of Regulation 26 visits being completed and that all reports are available for inspection by the CQC in future. 2 3 4 19 39 39 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!