Care Home: The Mountain Ash

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What the care home does well Mountain Ash is well maintained and decorated to a good standard. Individual bedrooms have been personalised. Staff advised that they are `well supported` and that the manager and deputy are `very approachable`. A staff member stated that the manager has always told them that `the door is always open if they need to talk`. The home ensures that all staff are given specialist training to equip them to meet the complex needs of the residents accommodated. Sixteen of the twenty three care staff have completed NVQ (national vocational qualification) at level two or above. Residents have opportunities to participate in a variety of activities throughout the day. The hydro pool on site means that residents have the benefit of regularly using this facility. In addition the home has a sensory room, which residents also enjoy using. All residents have an annual holiday. What has improved since the last inspection? The home is in the process of introducing a new format for care planning called ELP (essential lifestyle plans) and work carried out to date has been of a very good quality. New risk assessments have been compiled, which provide detailed advice and guidance for staff to minimise the risk of accidents/incidents occurring. Health action plans are also being drawn up in relation to all residents and again work seen in relation to this was excellent. The laundry facility, which was previously sited in one of the bathrooms has now been moved to another area of the home. New carpets have been fitted in a number of areas, door closures have also been fitted and new furniture has been purchased for the lounge areas. The providers ensure that detailed compliance visits are carried out and that any shortfalls are identified. This ensures that the home is continually monitoring and auditing the quality of the care that is provided. What the care home could do better: No requirements or recommendations have been made as a result of this inspection. Key inspection report Care homes for adults (18-65 years) Name: Address: The Mountain Ash Fairlight Gardens Fairlight Cove East Sussex TN35 4AY     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Caroline Johnson     Date: 2 7 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 26 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 26 Information about the care home Name of care home: Address: The Mountain Ash Fairlight Gardens Fairlight Cove East Sussex TN35 4AY 01424812190 01424814500 mountainash@evesleighcaregroup.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Cove Care (Mountain Ash Residential Home) Ltd care home 11 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: The maximum number of service users to be accommodated is 11. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) Physical disability (PD). Date of last inspection Brief description of the care home The Mountain Ash provides care and accommodation to eleven adults with a severe learning disability. The majority of service users also have a physical disability. The Registered providers are Cove Care (Mountain Ash Residential Home) Ltd. Cove Care Limited is in turn owned by the Independent Living Group Limited who also own a number of homes in the area. The home is a converted hotel situated in the village of Fairlight. Ore, on the outskirts Care Homes for Adults (18-65 years) Page 4 of 26 11 11 Over 65 0 0 Brief description of the care home of Hastings, with shops, amenities and railway station, approximately three miles away. All accommodation is at ground floor level; bedroom accommodation consists of eleven single rooms. Communal accommodation comprises of two lounges and a dining room. Other facilities include a relaxation [sensory] room, an indoor swimming pool and gardens. The home has two minibuses. The range of fees charged for service are from 1014 to 1734 pounds per week. Additional charges are made for personal items such as toiletries, holidays, hairdressing additional outings such as the theatre and clothes, and additional pub and restaurant meals. Inspection reports are not routinely sent out to families and advocates after each publication although a copy is kept on display in the reception area of the home and can be obtained via the manager. Care Homes for Adults (18-65 years) Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: For the purpose of this report the people living at Mountain Ash will be referred to as residents. As part of the inspection process a site visit was carried out on 27 January 2010 and it lasted from 10:10am until 17:20pm. The deputy manager facilitated the inspection. During the visit there was an opportunity to meet with and observe the residents in their surroundings. Time was also spent talking with staff generally in the course of their duties and time was spent with two members of care staff in private. Two care plans were examined in detail. Other documentation seen included:- staff rotas, training, menus, health and safety, quality assurance and leisure activities. Care Homes for Adults (18-65 years) Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 26 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 26 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. The home ensures that they can meet the assessed needs of the residents accommodated. Evidence: The home currently has a combined statement of purpose and service user guide. They are in the process of producing two separate documents. Staff advised that they are taking photos that will be incorporated into the service user guide to make it more user friendly. There is currently one vacancy. The home has a block contract with East Sussex County Council and are awaiting referrals for this vacancy. Residents needs are assessed on a continuing basis and details of how residents communicate are stated in each of the care plans. There have been no new admissions to the home since the last inspection. Care Homes for Adults (18-65 years) Page 9 of 26 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. Care plans provide detailed information about the assessed needs of the residents and this will be enhanced further when all of the care plans have been updated to the same quality. Evidence: The home is in the process of rewriting all the care plans using a new ELP (essential lifestyle plan) format and the target date for completion of this work is the end of March 2010. Two care plans were examined on this occasion one in the new format and one in the old format. In the care plan that was in the old format it was noted that the majority of plans had been written a number of years ago but there was evidence that they had been reviewed at regular intervals. Keyworker reports are written on a monthly basis. Staff advised that care plans are reviewed on an ongoing basis. Where there is a perceived risk there is a risk assessment in place. A new format for carrying our risk assessments RAMP (risk assessment and management protocols)has been introduced. Care Homes for Adults (18-65 years) Page 10 of 26 Evidence: In one case there was a very detailed health action plan in place and it was noted that this document included far more advice and detail than the care plan. It was reported that once all action plans and care plans have been updated they will all be to the same quality. The second care plan seen had been updated and advice and guidance was very detailed. Each of the residents has a number of goals that they are working on. Staff advised that progress with these goals is recorded in daily diaries and in keyworker reports. However, evidence regarding progress was not seen. For one resident the goals were to encourage finger feeding and to encourage the resident to participate in arts and crafts. Whilst the resident would have had opportunities to be involved in arts and crafts there was no written evidence of progress. For the second resident the goals were around feeding their fish, regular exercise and learning to play their electronic games. There was a lot of evidence that the resident was having regular exercise but no evidence in relation to the other goals. It was also not clear just how much support would need to have been given with the electronic games so that staff would have an indication of how much support they would have to give. Daily records are kept detailing the personal care given, what activities residents have participated in and general statements about how the resident was on a given day. The records indicate that residents are making a range of choices regarding the food they eat for breakfast and the clothes they wear. Care Homes for Adults (18-65 years) Page 11 of 26 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. Residents are offered a variety of interesting and stimulating activities. Evidence: Each resident has an activity programme in their care plan. A number of the residents attend day centres three days a week. Structured activities are also provided inhouse. The home has a hydro therapy pool on site and residents can make use of this facility during two week days, evenings and at weekends. In-house activities include arts and crafts, cookery, music, painting, board games and use of the homes sensory room. Six of the residents attend a music gym in Hastings one day a week. Staff also advised that regular day trips are organised to places like Dover, Leeds castle and to the zoo. Regular trips are also taken to the White Rock theatre for a show and a meal. Residents enjoy visits to cafes and restaurants. Care Homes for Adults (18-65 years) Page 12 of 26 Evidence: Staff advised that they support residents to maintain contact with their families and two of the resident enjoy regular weekend stays with their relatives. Some of the residents enjoy observing household tasks being carried out such as cooking, washing up and laundry duties. Residents benefit from having an annual holiday and this has already been booked for this year. On the day of inspection in-house activities included arts and crafts in the morning and cake baking in the afternoon. The baking session was observed for a while. As residents have complex needs some in terms of physical disabilities, involvement in tasks is often limited. However it was noted that staff tried to encourage residents to participate in this activity. One resident opted out of the activity and it was obvious that the other residents enjoyed the activity. A staff member stated that the cookery session is one of the favourite activities. They also stated however, that the arts and crafts sessions are mainly residents observing rather than participating in the activity. The home is continuing to look for additional activities that residents can have an active participation in. There is a four week menu in place that is varied and well balanced and this is adjusted on a seasonal basis. Special food diaries are maintained in relation to three residents. A record is kept of the meals served and staff advised that they very rarely have to serve alternatives. A record is kept in individual daily records of the quantity of the meal that have been eaten. In relation to one resident it was noted in their care plan that there were guidelines from a visiting professional regarding how best to support the resident at meal times and advice on types of food to avoid. It stated to avoid sandwiches. The guidelines had also been laminated and were on display in the kitchen area. However, it was noted that one of the goals for this resident was to encourage independence with finger foods such as sandwiches. A staff member said that this has been discussed with the SALT (speech and language therapist) team who gave agreement to this, however records need to be updated to reflect this and to update the guidelines. Care Homes for Adults (18-65 years) Page 13 of 26 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 home is good at ensuring that the healthcare needs of the residents continue to be met. Evidence: There are arrangements in place to ensure that residents attend regular health appointments such as dental, opticians and chiropody. A number of professionals are involved in assisting staff to meet the complex needs of some of the residents. Where guidelines have been drawn up by healthcare professionals these have been incorporated into residents support plans. Staff were observed to be courteous and friendly in their care of residents and there was a very calm and relaxed atmosphere in the home. Staff receive medication training and they must also complete a competency assessment on an annual basis. The company has identified a number of courses that are essential for the staff at Mountain Ash to attend to meet the specific needs of the residents accommodated. These include caring for individuals who have epilepsy and diabetes. Care Homes for Adults (18-65 years) Page 14 of 26 Evidence: The home are in the process of compiling health action plans for residents. At least half of the residents have a completed plan on file. The quality of the plan see was very good. The arrangements in place for the storage and handling of medication were examined and were in order. It was noted that a small number of staff are trained to administer invasive medication to one resident on a regular basis. However it was reported that it is a number of years since staff received training on this subject. It was recommended that this be discussed with the visiting District Nurse. The wishes of residents and the views of residents families have been assessed in relation to dying and death and in each case a detailed funeral plan has been put in place for residents. Care Homes for Adults (18-65 years) Page 15 of 26 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 systems in place to ensure that anyone who wishes to make a complaint can do so. Evidence: It was reported that there have been no complaints since the last inspection of the home. There is a detailed complaint procedure in place. A simplified version of the procedure is available but it was noted that this version would not be appropriate for the majority of the residents. The home is in the process of making the policy more user friendly and the updated version will be included in the new service user guide. There are a range of systems and procedures in place to assist staff in recognising how residents might show signs of unhappiness. Staff spoken with stated that despite limited verbal communication skills residents are able to show signs of unhappiness, for example one resident goes very quiet and another touches a particular part of their face to indicate that all is not right. Details of how residents display unhappiness is included in care plans. There is a detailed procedure in place on the protection of vulnerable adults. Records showed that all of the staff team have had training on the subject. Staff spoken with were clear about what they should do if they suspected abuse of any form. There is a flow chart showing the steps that need to be taken if abuse is suspected on display in the home. It was noted that following a safeguarding investigation the home took Care Homes for Adults (18-65 years) Page 16 of 26 Evidence: appropriate action in dealing with the incident but it was not clear if a referral had been made to the ISA (Independent Safeguarding Authority) as is required in relation to such circumstances. Care Homes for Adults (18-65 years) Page 17 of 26 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 well maintained and decorated to a good standard. Evidence: The home is well maintained and decorated to a good standard. Since the last inspection of the home carpets have been replaced in some areas and the lounge and dining rooms have been repainted and new furniture has been purchased for the lounges. The laundry which was originally in one of the bathrooms has now been re sited to a room elsewhere in the building. It was noted that there was a bolt lock on the outside of the door of one of the bathrooms and the home was advised that this was inappropriate. By the end of the inspection the lock on this door had been replaced. Communal areas were seen during the inspection and these include two lounges, a sensory room and a dining room. In addition there is a hydro therapy pool on site and residents have access to this area two days a week and at the weekends. Within the pool area there are hoist facilities and specialist changing areas. The pool is available for hire by the wider community, outside of the times used by the residents of the home. Care Homes for Adults (18-65 years) Page 18 of 26 Evidence: At the time of the ASR (annual service review) carried out in April 2009, the home had advised that they had plans in place for the fitting of over hoists in bedrooms and that additional equipment was to be purchased for the sensory room. It was noted that these have been temporarily put on hold but it is hoped that these works will be carried out in the coming year. A detailed fire risk assess met was in place and it was noted that actions recommended as a result of this had been addressed. Staff have regular opportunities to participate in fire drills. All areas of the home seen during the inspection were clean and fresh. All staff have had training on infection control. Staff responsibilities in relation to cleaning are detailed on the daily handover report and cleaning staff also have a cleaning schedule detailing their responsibilities. A daily premises check is carried out to check that standards have been maintained. Care Homes for Adults (18-65 years) Page 19 of 26 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. There is a well trained staff team that have the skills required to meet the needs of the residents accommodated. Evidence: The rotas seen showed that there are generally five staff on duty through the day and two waking night carers at night. Care staff take it in turn to cook and a member of staff is employed to carry out cleaning duties five days a week, working five hours each day. Recruitment records were seen in relation to two staff members and this showed that the home were thorough in ensuring that appropriate checks were being carried out. One staff member was still waiting for their CRB (criminal records bureau) check to come through and records showed that this staff member was being supervised when providing personal care to residents. New staff complete a detailed induction to the service. A staff member spoken with stated that the induction she received was very thorough. Records showed that all staff are provided with regular opportunities to attend mandatory training and in addition to attend more specialist training that has been identified as essential to meet the needs of the residents at Mountain Ash. Sixteen of the twenty three care staff Care Homes for Adults (18-65 years) Page 20 of 26 Evidence: have completed a National Vocational Qualification (NVQ) at level two or above. Staff spoken with had received an annual staff appraisal. Records showed that all staff received between 3-5 formal supervisions during 2009. A list had been drawn up for 2010 and progress was being made in ensuring that all staff receive a supervision on a regular basis. Care Homes for Adults (18-65 years) Page 21 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run well in the interests of the residents accommodated. Evidence: The manager Mrs Julie Dignum holds an Advanced Management in Care qualification as well as the Registered Managers Award. She has been the manager at Mountain Ash for the past nine years. There is a detailed handover system between each shift. Staff sign in and out of the home. In addition residents are also signed in/out. Daily activities are stated and all routines are detailed. Personal care is detailed along with who supported whom and what care was provided. Also stated are which staff member has been assigned responsibility for keys, medication and household checks. Activities planned for the day are also stated. Staff spoken with stated that that manager and deputy are very approachable and supportive. One staff member stated that they are always told that the door is always open if they need to talk. Care Homes for Adults (18-65 years) Page 22 of 26 Evidence: Staff meetings are held monthly and detailed minutes are kept of the outcome. Minutes showed who had responsibility for each issue raised and the timescale by which it should be achieved. All staff sign to indicate that they have read the minutes and if they are unable to attend a meeting they give apologies in writing. There was no written evidence that there were any discussions or that staff views were heard. The minutes included a list of instructions for staff. However, staff spoken with all stated that their views are heard and that meetings are used to discuss a variety of topics. One staff member stated that recently they have asked to have a meeting of care staff only. Representatives from this meeting will then attend a seniors meeting to provide feedback on the outcome of the carers meeting. This will enable anyone who is not keen on speaking out in a large group to share their views. As part of the homes quality assurance system surveys are sent to relatives of residents on an annual basis. Records showed that they had been sent out in December 09. Six returns were received and in each case the outcome was very positive. Relatives mainly chose to use the tick box. One relative asked that the home please keep in contact with me. It was not clear if any feedback was given to relatives on the outcome of the survey. Surveys were also sent to visiting professionals in December 2009. It was not clear what the outcome of the survey was. It was noted that no surveys are completed by residents or staff. The deputy manager advised that they have had discussions recently about introducing a staff survey. A compliance officer visits the home once a month to report to the Responsible Individual on the running of the home. It was noted that at the end of November 2009 a detailed internal compliance report was written. The organisation had carried out their own inspection of the home in relation to each of the standards. This found that 31 standards were good, seven were almost met and one was not met. The report was very thorough and provided the home with detailed advice and guidance in relation to any shortfalls noted. The company carried out a health and safety audit in February 2009. A number of issues were picked up as part of this process. Regular in-house health and safety meetings are also held and minutes show the progress made in achieving the areas identified in the annual audit. Records show that equipment is tested and serviced at regular intervals. Care Homes for Adults (18-65 years) Page 23 of 26 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 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 25 of 26 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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