Care Home: Tudor Lodge

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What the care home does well `The staff are very good, I get all the support I need`. Comment from a resident. `I make my own decisions every day`. Comment from a resident. `I can do most things for myself, but the staff will always help if I ask them`. Comment from a resident. `The manager is excellent, I feel very supported when I do my job`. Comment from a member of staff. `We have clear policies and procedures that help us to do our work`. Comment from a member of staff. We found that standards of care planning and risk management in the home were excellent. People living in the home were fully involved in planning and reviewing the care and support they received. The home had a team of qualified and experienced staff who worked well together to meet people`s identified care needs. A qualified and experienced manager provided good leadership and support to the staff team. The home provided excellent standards of private and shared accommodation. People`s bedrooms were well decorated and comfortably furnished and there was a choice of shared areas where residents could spend time with each other or with visitors. What has improved since the last inspection? When we last inspected the home in February 2007 we made one requirement for the provider to tell residents and their representatives the results of a quality monitoring exercise that had been carried out. This requirement had been met when we completed an Annual Service Review of the home in 2008. What the care home could do better: Following this inspection we have concluded that the home continues to provide excellent outcomes for people who live there. We have made no requirements in this report. We have made one recommendation that the provider should update information in the home`s terms and conditions of residence. Key inspection report Care homes for adults (18-65 years) Name: Address: Tudor Lodge 164 Green Lane Edgware Middlesex HA8 8ET     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: Tony Lawrence     Date: 1 4 1 2 2 0 0 9 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 27 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 27 Information about the care home Name of care home: Address: Tudor Lodge 164 Green Lane Edgware Middlesex HA8 8ET 02089589932 02089589670 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Anjalee Bhurton care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home Tudor Lodge is a residential care home providing personal care for five people with a mental illness. The home is privately owned and the provider is also the registered manager. The home is a large converted two-storey, detached domestic house that is very well decorated and maintained. The ground floor contains the communal lounge, kitchen/ diner, two bedrooms and a separate toilet. The first floor has three bedrooms, one of which has en-suite shower facilities, a bathroom/ toilet and staff facilities/ managers office. There is a large attractive garden to the rear. The home has a range of additional handrails on the stairs and in the bathroom although is not suitable for service users with a significant physical disability. The home is situated in a quiet and attractive residential area of North London and is located within convenient travelling distance to both public transport and the major road network to central London and the M25 motorway. The stated objective of the home is to provide care to all service users to a standard of excellence that embraces fundamental principles of good care practice. It also aims to provide its service users with a secure, relaxed and Care Homes for Adults (18-65 years) Page 4 of 27 Over 65 0 5 Brief description of the care home homely environment in which their care, well being and comfort is of prime importance. The current scale of charges can be obtained from the homes owner / manager. A copy of this report is available on the CQC website or/and from the home. Care Homes for Adults (18-65 years) Page 5 of 27 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: This unannounced key inspection of Tudor Lodge took place on Monday 14th December 2009 from 09:20 - 14:15. Tony Lawrence, Local Area Manager, carried out the inspection on behalf of the Commission. Throughout this report, the words we and us are used to represent the Commission. During this visit we assessed outcomes for people living in the home against the National Minimum Standards for care homes for adults. We did this by talking to all 5 residents, staff and the owner / manager, checking care records kept in the home and touring the building. The provider also sent us an Annual Quality Assurance Assessment (AQAA) in November 2009 and this gave us useful information about the home that we have used to write this report. Care Homes for Adults (18-65 years) Page 6 of 27 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 27 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 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Peoples care needs are well assessed and they are given enough information to make an informed choice to move into the home. Evidence: My family visited and Im happy they chose the right place for me. Comment from a resident. The manager talked to me about the help I need before I moved in. Comment from a resident. We do our best to make sure that people are not deprived of their rights as citizens. We therefore work to maintain our service users place in society as fully participating and benefiting citizens in every way possible. Extract from the providers Annual Quality Assurance Assessment (AQAA). Care Homes for Adults (18-65 years) Page 9 of 27 Evidence: During this inspection we reviewed the care of two people living in the home. We did this by talking to them about how they had come to live in the home and what information they had about the home before moving in. Both people told us that they had been able to visit the home before moving in and both said that they had enough information to make an informed choice to move in. We saw that the homes owner / manager had completed detailed care needs assessments with both people before they moved in. The assessments covered each persons care needs and also included their views about the support they needed. We also saw that the manager had obtained copies of reports and assessments written by health and social care professionals working with each person. This showed us that the manager made sure that each residents care needs could be met before they moved into the home. The two residents care plan files we checked during this visit included a copies of the homes terms and conditions of residence and we saw that these had been signed by each person. We saw evidence that staff had discussed the terms and conditions with the residents as part of the admission procedure and this was confirmed by people who spoke to us. Following this inspection we have made a recommendation that the owner should update the terms and conditions to include information about the homes current registration with the Commission. Care Homes for Adults (18-65 years) Page 10 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience Excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has excellent standards of care planning and risk management and people are fully involved in planning the support they need. Evidence: The staff are very good. I get all the support I need. Comment from a resident. I make all of my own decisions every day, but the staff are there if I need them. Comment from a resident. We aim to ensure that our service users have as much freedom of choice in their lives as is possible within a communal, care environment; so long as that freedom does not expose them, or any other service user or member of staff to unacceptable risk or intrudes on the freedom of other service users to enjoy their lives. Extract from the providers Annual Quality Assurance Assessment (AQAA) Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: During this visit we reviewed the care plans for two people living in the home. We saw that each person had an excellent Service User Plan that detailed their care and support needs and how these would be met in the home. Each plan included clear long term aims and shorter term objectives that covered each persons mental health needs, finances, personal and fire safety, daily activities and personal care. We saw evidence that these support needs had been agreed with each person and they had commented on and signed their own plan. The plans had been reviewed regularly, one in June 2009 and the other in September 2009. These excellent plans showed us that people living in the home were involved in agreeing the support they received as well as goals that were reviewed regularly and updated. We also spoke with all five people living in the home and they told us that they worked with staff to agree and review their own support plans. Residents also told us that they were able to make choices about aspects of their daily lives. They told us they were able to choose what to wear and eat each day and how to spend their time, with support from staff if needed. All five people told us that they were registered to vote in local and national elections. During this visit we also reviewed the homes risk management systems. We did this by talking to residents and staff and checking the risk assessments completed for two people. The staff we spoke to had a good knowledge of each residents care needs and potential risks. They told us about the risk assessments they wrote with each person and how these were reviewed regularly. We saw that individuals risk assessments covered self neglect, management of finances, smoking, mental health and personal safety. The assessments clearly identified possible risks for each person and gave staff clear guidance on how these should be minimised. All of the risk assessments we saw had been reviewed and updated in September or October 2009. Care Homes for Adults (18-65 years) Page 12 of 27 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 using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in appropriate activities and to maintain contact with family and friends. Standards of catering in the home are very good. Evidence: I mostly do what I want, the staff are always there to help me if I need it. Comment from a resident. The foods good. Staff do most of the cooking, but I help sometimes. Comment from a resident. I go out, but I need the staff to go with me. I usually go out two or three times a week. Comment from a resident. Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: We support service users to maintain their family links and existing friendships both inside and outside the home. We welcome family and friends and their involvement in the service users care is actively encouraged, subject to the service users agreement. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit we spent time talking with each of the people living in the home. They were all very positive about their experiences living at Tudor Lodge and the support they received from the provider and staff team. We saw that peoples care and risk management plans included details of their daily routines. Four people told us that they were able to go out when they chose and we saw evidence from daily care notes completed by staff that these people went out every day. One person needed more support because of their physical disability. They told us that this support was always available from staff and they could go out whenever they chose. People told us that they were able to visit family and friends and go shopping locally and in other parts of London. People told us that they could take part in leisure activities they preferred, either in the house or the local community. We saw from peoples care plans that the contact details for relatives, friends and other significant people were well recorded. People told us that they were able to see or speak to these people at any time and we saw that staff recorded this contact in the daily care notes for each person. All five people told us that they were registered to vote in local and general elections and that staff would support them if necessary. All five people living in the home were very positive about the meals provided. People told us that there was always a choice at mealtimes and the food provided was fresh and plentiful. The home uses a 3 weekly menu and we saw that a good variety of nutritious meals was provided. People told us that they usually ate together in the kitchen / dining room, but they could choose to eat elsewhere, if they preferred. Care Homes for Adults (18-65 years) Page 14 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We found that peoples personal and health care needs were well assessed, reviewed and recorded. Medication was well managed and people got the medication they needed. Evidence: I can do most things for myself, but the staff will always help if I ask them. Comment from a resident. I get a lot of help from my CPN and the hospital and the staff here make sure that I take my tablets. Comment from a resident. We ensure that we provide personal care to our service users on the basis of thorough assessments of their individual needs, which is specified in their service user plan. The amount of assistance or support we provide to service users is always discussed and agreed by them first. Extract from the providers Annual Quality Assurance Assessment (AQAA). Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: During this visit we spoke to all five people living in the home. All were very positive about the support they recieved with their personal and health care. They told us that staff encouraged them to be as independent as possible and that their care plans included clear goals and objectives. Most people said that they managed their personal care independently and staff supported them to make sure their physical and mental health care needs were met. We saw evidence in the two care plans we checked during this inspection that staff involved residents fully in the assessment and review of their health care needs. We saw good evidence that this was done through some excellent joint work with each individuals GP and mental health services. Staff kept a good record of each persons health care appointments and this showed us that they regularly saw their GP, District Nurse, Community Psychiatric Nurse and dentist. The care plans we checked had been regularly reviewed and updated and we saw evidence that residents were involved fully in each review. The provider told us that the home used a monitored dosage system provided by Boots for all prescribed medication. We saw that all prescribed medication was securely stored in a lockable cabinet in the managers office. We checked the Medication Administration Record (MAR) sheets for all five people living in the home. We saw that these records were well completed and they gave us good evidence that each person consistently received the medication they needed. We also saw that the staff kept excellent records of all medication given as required. Care Homes for Adults (18-65 years) Page 16 of 27 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. People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We found that people living in the home were supported to advocate for themselves and were cared for and supported safely. Evidence: If I was worried about anything Id talk to the manager or the staff. Comment from a resident. Ive never made a complaint but I know the staff would take it seriously. Comment from a resident. We believe that our service users must always be safeguarded from all forms of abuse and we ensure that at all times to protect our service users from any form of abuse. We take every possible action to prevent abuse and deal with it as promptly and effectively if it occurs. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit residents told us that they knew about the homes complaints procedure. They said that they had been told when they moved into the home how to make a formal complaint and how it would be dealt with. None of the five people we spoke to had made a formal complaint. They told us that any disagreements or Care Homes for Adults (18-65 years) Page 17 of 27 Evidence: dissatisfaction were dealt with by staff at the time and the formal complaints procedure was not needed. We checked the homes complaints record and saw that there had been no formal complaints in the past 12 months. The provider told us that all staff working in the home had completed safeguarding adults training and this was confirmed by staff we spoke with. We also saw that the home had a copy of the local authoritys safeguarding adults policy and procedures. The provider confirmed that there had been no safeguarding concerns or referrals in the last 12 months. Care Homes for Adults (18-65 years) Page 18 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides excellent standards of private and communal accommodation. Evidence: I really like my room, Ive got everything I need here. Comment from a resident. Everythings great - its always clean and tidy. Comment from a resident. The environment has been designed to encourage and support the independence of our service users, while promoting their support and safety. The provision of private rooms and quiet, restful areas has been balanced with homely, communal areas where service users can mix and be with each other. Extract from the providers Annual Quality Assurance Assessment (AQAA). Tudor Lodge is a 2-storey detached property in a residential area, close to public transport, shops etc. There are two residents bedrooms on the ground floor, with a lounge, kitchen / dining room and WC. On the first floor, there are three residents bedrooms, a bathroom and the staff office. There is a large, attractive garden at the back of the home. Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: During this unannounced visit we saw all communal parts of the home and two residents bedrooms, with their permission. All parts of the home we saw were clean, tidy and hygienic. Residents bedrooms were well decorated and comfortably furnished. People told us that they were able to bring their own possessions into the home and the rooms we saw were very individual. Communal areas were comfortable and offered a variety of spaces for residents to spend time, alone or with visitors. Overall, we found that the home provides excellent standards of accommodation. Care Homes for Adults (18-65 years) Page 20 of 27 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We found that the home had a qualified and experienced staff team who worked well together to meet the care needs of people living in the home. Evidence: The staff are very good, they always help you if they can. Comment from a resident. There are always enough staff on duty and we can always get extra people if we need to. Comment from a member of staff. We have deployed a staff team that has both sufficient numbers and the right blend of qualities and skills to meet service users needs. Extract from the providers Annual Quality Assurance Assessment (AQAA). During this visit, people living in the home spoke very positively to us about the support they received from the homes staff team. They said that there were always enough staff available and that all staff responded promptly to requests for support. People told us that they thought staff understood their care needs and worked well together to help them become more independent. During our visit we saw that staff Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: worked well together to support people living in the home. The staff rota showed us that there was a minimum of two staff on duty during the day. At night, one person was available in the home to support people, if required. Staff told us that they were able to call in additional staff for support if required. We checked the staff files for two people working in the home. We found that both files included an application form, written references, proof of each persons identity, a Criminal Records Bureau (CRB) check and copies of training certificates. This was evidence that the provider takes all the steps necessary to make sure that suitable staff are recruited to work with vulnerable people living in the home. The training records we saw showed us that staff were well trained. Both of the staff we checked had completed their National Vocational Qualification (NVQ) Level 3 training, as well as other essential skills training. We also saw evidence that each member of staff met regularly with the manager to talk about their work, the support provided to residents and their personal development. This showed us that staff were well supported and encouraged to develop their professional skills. Care Homes for Adults (18-65 years) Page 22 of 27 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. People using the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a qualified and experienced owner / manager who makes sure that the best possible outcomes are achieved for people living in the home. Evidence: The manager is excellent, I feel very supported when I do my job. Comment from a member of staff. We have clear policies and procedures that help us to do our work. Comment from a member of staff. We ensure that the homes services are monitored and continuously improved. We ensure that service users are confident that their views are important in all selfmonitoring, review and development of the home. Extract from the providers Annual Quality Assurance Assessment (AQAA). Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: During this visit the homes owner / manager told us that she had more than 13 years experience of providing residential care for people with a mental illness. The manager had completed the National Vocational Qualification (NVQ) Level 4 training for care home managers and we have registered her as a fit person to manage a residential care home. During this visit the owner / manager demonstrated an excellent awareness of best practice and recent developments in the care of people with a mental illness and planned changes in the regulation of care services. The staff we spoke with were very positive about the leadership and management approach of the homes owner / manager. The owner / manager sent us the Annual Quality Assurance Assessment (AQAA) when we asked for it in November 2009. The AQAA was well completed and gave us useful information about the home that we have used as part of this inspection. The AQAA also showed us that the provider was aware of issues that needed to be addressed to further improve outcomes for people living in the home. The AQAA included evidence that the provider had developed all of the policies and procedures needed to meet these Standards and these were regularly reviewed and updated. The provider told us that she carried out a survey every six months to get the views of people involved with the service, including residents, their relatives and people involved in their care. The surveys were used to develop an action plan and the owner told us that any concerns highlighted in the surveys were addressed immediately. People living in the home also told us that a monthly community meeting was held to discuss any issues or concerns. During this visit we checked a variety of care records kept in the home. We found that standards of record keeping were very good and residents could be confident that their care needs would be accurately recorded, together with action taken by staff to meet agreed goals and objectives. We also checked health and safety records kept by the staff and these showed us that regular checks were completed and equipment was regularly inspected and serviced. We saw no health and safety issues during this inspection. Care Homes for Adults (18-65 years) Page 24 of 27 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 25 of 27 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 5 The owner should update the residents terms and conditions to include information about the homes current registration with the Commission. Care Homes for Adults (18-65 years) Page 26 of 27 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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