Care Home: Willow End

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What the care home does well PRE SERVICE ASSESSMENT REPORT The manager makes sure that people have their needs assessed before they move in.The care plans are excellent and are written around what the person getting the service wants.People are encouraged to make their own decisions about their everyday lives such as food and activities.People get lots of opportunities to go out in the local community; they go to college, to the shops, bowling, and golf and to the cinema.Staff gets lots of training and is well supported to do their job. What has improved since the last inspection? The home has redecorated the bathroom and replaced the flooring. What the care home could do better: Abuse policy The abuse policy needs to show the right actions that staff must take if they suspect abuse.The manager must make sure that all of the staff has proper checks before they start work.The manager must keep copies of the report that is written as a result of the provider`s monthly visits.FIRE DRILL RECORDS The manager must make sure that fire drills take place so that people know what to do if there is a fire and the fire records should always be completed to show that the right checks have been done. Key inspection report Care homes for adults (18-65 years) Name: Address: Willow End 82a The Willows Mersea Road Colchester Essex CO2 8PX The quality rating for this care home is: two star good 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: Pauline Marshall Date: 1 5 1 2 2 0 0 9 This report is a review of the 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 stars – excellent  2 stars – good  1 star – adequate  0 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. They reflect the things that people have said are important to them: 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 37 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 37 Information about the care home Name of care home: Address: Willow End 82a The Willows Mersea Road Colchester Essex CO2 8PX 01206769713 N/A willowhealth@btconnect.com 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) : Willow Health Limited care home 7 Number of places (if applicable): Under 65 Over 65 7 5 0 0 learning disability physical disability Additional conditions: Five people with a learning disability who also have a physical disability whose names were provided to the National Care Standards Commission in September 2002 Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 7 persons) The total number of service users accommodated must not exceed 7 persons Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 37 A bit about the care home Willow End is a detached, purpose built bungalow that is in a residential area; it provides a home for seven people who have a learning disability. There are shops a few minutes walk away from the home where people can buy sweets, papers and magazines. You can get a bus nearby that takes you into Colchester town centre, which is about a mile away. Care Homes for Adults (18-65 years) Page 5 of 37 Each person has their own bedroom this means that nobody has to share a room and there is plenty of other space for people to use. ON THE MINI BUS The home has its own minibus for people to use to get them to college, to social clubs and to go shopping. Four of the bedrooms have their own shower, washbasin and toilet. The other three bedrooms have washbasins and there is a bathroom for people to use that has an assisted bath to help them to get in and out of it. Care Homes for Adults (18-65 years) Page 6 of 37 There is a large garden around the home which has a pagoda; there is a table and chairs, a trampoline and a swing in it for people to use when they want to. The garden has a large area of grass and there are borders of flowers and shrubs. There is parking for several cars at the front of the home. The manager gives people that want to move to Willow End a copy of her Statement of Purpose and Service User Guide. Care Homes for Adults (18-65 years) Page 7 of 37 The cost for living at Willow End is between £964.00 and £1069.11 each week and people are asked to pay a contribution of between £63.95 and £69.90 per week towards this. People also have to pay for their toiletries, hairdressing, clothing, holidays, dry cleaning and the maintenance and the running of the minibus. Care Homes for Adults (18-65 years) Page 8 of 37 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 Care Homes for Adults (18-65 years) Page 9 of 37 How we did our inspection: This is what the inspector did when they were at the care home We visited the home and looked at some of the files belonging to the people living in the home and the homes staff. We also looked at the policies that explain how the home does things. We looked around the home and spoke to the staff and to the manager. We read the information (AQAA) sent to us by the manager. The AQAA is a form required by law for the manager or provider to carry out a self-assessment of how well Care Homes for Adults (18-65 years) Page 10 of 37 the outcomes of people using their services are being met. We sent surveys to the seven people that live at Willow End, to four professional people that visit the home and to seven of the homes staff, to see what they think about it. We received two completed surveys from people that use the service and we have added their comments to this report. We did not receive any other surveys. What the care home does well Care Homes for Adults (18-65 years) Page 11 of 37 PRE SERVICE ASSESSMENT REPORT The manager makes sure that people have their needs assessed before they move in. The care plans are excellent and are written around what the person getting the service wants. People are encouraged to make their own decisions about their everyday lives such as food and activities. Care Homes for Adults (18-65 years) Page 12 of 37 People get lots of opportunities to go out in the local community; they go to college, to the shops, bowling, and golf and to the cinema. Staff gets lots of training and is well supported to do their job. What has got better from the last inspection The home has redecorated the bathroom and replaced the flooring. Care Homes for Adults (18-65 years) Page 13 of 37 What the care home could do better Abuse policy The abuse policy needs to show the right actions that staff must take if they suspect abuse. The manager must make sure that all of the staff has proper checks before they start work. Care Homes for Adults (18-65 years) Page 14 of 37 The manager must keep copies of the report that is written as a result of the providers monthly visits. FIRE DRILL RECORDS The manager must make sure that fire drills take place so that people know what to do if there is a fire and the fire records should always be completed to show that the right checks have been done. If you want to read the full report of our inspection please ask the person in charge of the care home Care Homes for Adults (18-65 years) Page 15 of 37 If you want to speak to the inspector please contact Pauline Marshall 03000 61 61 61 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 16 of 37 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 17 of 37 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 know that their needs can be met within the home. Evidence: The homes Statement of Purpose and Service User Guide were last reviewed in October 2009 and both documents provided people with sufficient information about the service it provides. The manager said in her AQAA the Statement of Purpose and Service User Guide is available in a pictorial and symbol format, and there were copies of both documents in this format on the care files that we looked at to confirm this. The last report showed that people were only offered a place at Willow End after a thorough detailed assessment had taken place and the manager said in her AQAA that people make visits to the home as part of their transition package. There has been no admissions to the home since 2004 and all of the pre-admission assessment documentation had been archived so was unavailable for inspection. The manager provided a copy of the new assessment documentation that would be used for any future admissions and it covered all areas of need such as personal, social and emotional. The document looks at health, medication, behaviour, activities, likes and dislikes and the persons independence skills. We spoke to the last person to be admitted and they Care Homes for Adults (18-65 years) Page 18 of 37 Evidence: confirmed that they visited the home before moving in. Each of the people living at Willow End had a contract showing their terms and conditions with the home in their care files. Care Homes for Adults (18-65 years) Page 19 of 37 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. People receive appropriate individualised care based on their identified needs. Evidence: We looked at three care files and they showed that the care plans had been devised with the full involvement of the person using the service and that they had been reviewed on a regular basis. All of the care plans that we looked at were well written, person centred and included pictorial and symbolic information to make them more accessible to the people they are written for. The information in the care plan is colour coded making it easy to identify the different documents that are in use. The care plans that we looked at provided staff with clear instructions on the level of support that people needed. Each of the three care files included an infringement of rights document that sets out how any infringement would be dealt with. There were behaviour charts and management strategies in place for people that needed them. People spoken with confirmed that they were involved in their care plans and that the care plans met their needs. There was a service user agreement to the care plan form on each of the three care files that we looked at and these were signed and dated by either the person using the service or their representative. Care Homes for Adults (18-65 years) Page 20 of 37 Evidence: The care plans showed that people using the service were involved throughout the assessment and care planning process and regular house meetings are held to discuss any issues around peoples care. The notes of the house meetings are written in a pictorial and symbolic format to make them easier to understand for the people living in the home and the subjects discussed included activities, meals, holidays and the Christmas party. One person living in the home said when spoken with we have a lovely time at Christmas and we will be having a party this Saturday and then I will be going home for Christmas. All of the information that is displayed around the home is in pictures, symbols and easy read words. Staff were observed interacting with people in a positive, relaxed and friendly manner. People spoken with said that staff were nice and friendly and that they were always willing to help me with what I want to do. There were completed risk assessments on all of the three care files that we looked at and these covered a variety of risks such as the use of manual handling equipment, epileptic seizures, diet and food preparation, the use of bed rails and behavioural issues. Each of the risk assessments included clear instructions to staff on how the risk was to be managed. Care Homes for Adults (18-65 years) Page 21 of 37 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 are well supported to live a lifestyle that meets their identified needs and preferences. Evidence: The care plans showed that people participate in a range of activities both at home and out in the local community; these include college courses in computing, cooking and daily living skills. The manager said in her AQAA we ensure that people are supported to continue their education at the local institute or training centre and the activities records confirmed this. The home has drawn up an activities timetable and this showed that people regularly access the local town on the bus and one person spoken with confirmed that they had taken a taxi independently to a local day centre. Another person living in the home regularly goes out on their own to the local shops to buy sweets and magazines. The manager said in her AQAA people now attend the Wilson Marriage Centre where they are fully engaged for the whole of their session. The manager explained that people Care Homes for Adults (18-65 years) Page 22 of 37 Evidence: had previously attended a day care centre and they had complained that all they did was sit around watching videos most of the time so they changed to the Wilson Marriage Centre. People spoken with confirmed that they are happy at the Wilson Marriage Centre and that they are kept fully occupied there. The activities timetable showed that people go bowling, to the cinema, to the putting green to play golf and to a local social club in addition to trips out to the shops. People spoken with talked of trips to the pub and to the leisure centre and to aqua-springs (as a spectator). The activities records showed that people regularly go to the local shops and into the town centre where there are cinemas a sports centre, a bowling alley, museums and cafes. Daily routines are built around the people living in the home and one person spoken with confirmed this by saying that staff helps them to do the things they want to do when they want to do them. We observed staff interaction with the people living in the home and it was good; people appeared relaxed and comfortable in the staffs company. The menus were devised taking into account the preferences of the people living at Willow End and the four week rolling menu is subject to change if a person wants an alternative to the meal offered. People choose what they would like to eat from pictures of prepared meals and the mealtime is flexible to suit their needs and preferences. The nutrition records showed that people had eaten a healthy balanced diet and people spoken with said that the food OK, lovely and good here. Care Homes for Adults (18-65 years) Page 23 of 37 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. People receive personal care in a way that suits them and their health care needs will be fully met. Evidence: People living in the home said when spoken with that the staff provided their care according to their preferences and the care notes showed that people chose their waking and going to bed times. The care plans clearly showed the level of support that people needed and people said when spoken with that they get the right level of support. Each person had their own personal equipment such as hoists and slings and beds that raise and lower. The manager said in her AQAA people have access to a physiotherapist, an occupational therapist, speech therapists and an epilepsy nurse specialist and the health records in the care files that we looked at confirmed this. We looked at three care files and the health records showed that people received a range of healthcare services including dental, chiropody, optical and specialists nurses. The care files showed that people are registered with a GP of their choice and people spoken with confirmed this. The home uses a monitored dosage system for its medication administration and all medication is stored in a locked cupboard in the office. The manager said that only senior Care Homes for Adults (18-65 years) Page 24 of 37 Evidence: staff administers medication but all staff are trained and the pharmacy provides regular annual updates; the next one is due in January 2010. In addition to the pharmacy training staff that administers the medication have been trained by Essex County Council and they have completed a medication workbook. The manager has also observed their practice and a record of this was seen in the staff files. The manager said that the pharmacy carries out an annual check on the homes medication system and that she carries out a monthly audit to ensure that medication is correct and the most recent audit showed that all of the homes medication was correctly recorded and accounted for. There are epilepsy first aid plans in place for the use of epilepsy as and when required (PRN) medication. The manager confirmed that all open packets and bottles were signed and dated by staff to ensure that they were used within an appropriate time. The last report showed that the home operates sound systems for the handling of medication that protect the interests of people using the service. Care Homes for Adults (18-65 years) Page 25 of 37 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 will be protected from harm and abuse. Evidence: The manager last reviewed her complaints procedure in July 2009; the procedure contained some incorrect information about the role of the Commission. The manager has since amended her complaints procedure and it now shows the correct role and the contact details of the Commission. The procedure is available in a picture and symbol easy read format to make it accessible for the people using the service. The manager said in her AQAA that there had been no complaints made to the home since the last inspection and the records confirmed this. People spoken with were aware of the complaints procedure and indicated that they would complain if they felt the need to do so; there was a copy of the procedure displayed in the hallway. The manager said in her AQAA that the safeguarding adults procedure was last reviewed in March 2009 and she provided us with copies of the homes Safeguarding Vulnerable Adults quality policy statement and Safeguarding Adults and Prevention of Abuse procedure; both documents were undated. The Safeguarding Adults and Prevention of Abuse procedure provided conflicting information on the investigation procedure; it stated that the CQC will make the decision on whether or not the company should investigate the issue. The flowchart on appendix 1 of the procedure showed the correct procedure and informed people that any suspected abuse had to be referred to the Local Authority, who would arrange a strategy meeting within five days. The manager has amended the procedure as a result of this inspection. Staff spoken with had a good awareness of Care Homes for Adults (18-65 years) Page 26 of 37 Evidence: safeguarding procedures and the staff files contained certificates to confirm that staff had been trained. The training matrix showed that training in safeguarding adults had last taken place in July 2009. Care Homes for Adults (18-65 years) Page 27 of 37 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. People live in a homely, comfortable safe environment. Evidence: Willow End has seven bedrooms and they were all well decorated and contained good quality furniture and fittings. Each of the rooms that we looked at contained peoples personal items and belongings. One person using the service showed us their room and said how comfortable it was and another person said that they decided what to have and what not to have in their room and this was clear because one person said I did not like the lampshade up as it made the room too dark so I asked staff to remove it and they did. There is ample communal space; as well as a lounge, dining room and communal bathroom there is a large activity room that has a kitchen area with a hotplate and microwave so that people can carry out simple cooking tasks. Since the last inspection the bathroom has been redecorated and the flooring has been replaced. The cleaning schedule showed that regular cleaning takes place and staff spoken with confirmed that they work together with the people using the service to make sure that the home is kept clean and tidy. The relative of one person living in the home said when spoken with the home is always clean and nice and two people said in their surveys that the home is always clean and fresh. The manager said in her AQAA that all staff have infection control training and the training matrix and certificates of training on the staff files confirmed this. Care Homes for Adults (18-65 years) Page 28 of 37 Evidence: The maintenance records showed when repairs were requested and although the date when the repair was carried out was not always entered in the maintenance records, there was invoices to confirm that the repairs were carried out in a timely manner. The home was clean, pleasant and hygienic. Care Homes for Adults (18-65 years) Page 29 of 37 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. People are cared for by a competent, well-trained and supervised staff team, who are safely recruited. Evidence: The manager said in her AQAA that eight of the homes ten staff have an NVQ in care and there were certificates on the staff files to confirm this. Staff were seen to treat people living in the home respectfully by asking them what they wanted and how they wanted to do things. People spoken with confirmed that staff treated them with respect. We looked at the staff duty rosters over a six week period and these showed that there are three staff on duty plus the manager throughout the day and one staff awake and one staff asleep at night. The duty roster included the full names and designation of the staff that were working and alterations were clear; the duty roster was signed and dated by the manager. We looked at three staff files and two of them contained all of the appropriate documents as required in the regulations, which included a completed application form, two written references and a satisfactory criminal records bureau (CRB) check. The third staff file belonged to a member of staff that had been recently recruited and who was in their induction period; this file contained a completed application form, one written reference and an ISA Adult First check. The manager said that she was awaiting the second Care Homes for Adults (18-65 years) Page 30 of 37 Evidence: reference and that throughout the induction period the member of staff is supervised at all times and the staff member confirmed that they had been supervised since starting work. A discussion took place around the importance of obtaining full and satisfactory information for all workers. The two established staff files that we looked at contained certificates of training in medication, food hygiene, the deprivation of liberties, administering Buccal Midazolam (in epilepsy), Autism, epilepsy awareness, health and safety, the control of substances hazardous to health (COSHH), risk assessment, conflict management and safeguarding adults. The training matrix showed that other training included advanced medication, infection control, food hygiene, first aid, adult literacy, inclusive communication in Essex (ICE) and person centred support planning. Staff spoken with confirmed that they felt well trained and that training opportunities were many. There were copies of supervision notes on the two established staff members files that we looked at and the manager has developed a clear support and supervision plan that includes two monthly one to one meetings with staff, monthly meetings for seniors, stress management meetings and emergency planning meetings. Staff spoken with said that they felt well supported and one staff said I love working at Willow End and the manager supports me well. Care Homes for Adults (18-65 years) Page 31 of 37 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. People live in a well run home that is run in their best interests Evidence: The manager has worked at Willow End since April 2006 and she is very experienced; she holds a City and Guilds Advanced Management for Care, an NVQ4 in Care and the Registered Managers Award. The manager is an NVQ assessor, a Makaton tutor and has training in inclusive communication and has undertaken a three year counseling course. The manager regularly updates her practice and has completed training since the last inspection in conflict management, epilepsy awareness, fire safety, healthier food and special diets, autism, the administration of rectal Diazepam, Buccal Midazolam, managing challenging behaviour and the common induction standards. The manager returned her completed annual quality assurance assessment (AQAA) and it provided us with all of the information that we asked for. The AQAA showed that regular visits are made by the provider to ensure that the regulations are being met; there was no records of these visits available for inspection in the home. The last three reports have since been provided for inspection and they looked at a range of the homes documentation and provided details of interviews with both the staff and the people using Care Homes for Adults (18-65 years) Page 32 of 37 Evidence: the service. Action points were made, however, these were not always followed up at the next visit. The manager said in the homes Statement of Purpose that fire drills take place four times a year and that one of these is at night and the fire records showed that one fire drill had taken place in 2009. The responsible individual had reported this as a required action in the homes regulation 26 report on the visit that took place on 26/10/2009. A random sample of safety certificates were checked and they were all found to be in place and up to date. Care Homes for Adults (18-65 years) Page 33 of 37 Are there any outstanding requirements from the last inspection? Yes  No  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 34 of 37 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 Description 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 Description Timescale for action 1 22 13 The manager must ensure that there are appropriate procedures in place for the safeguarding of vulnerable audits. 31/01/2010 To ensure that people are protected from harm or abuse. 2 34 19 The manager must ensure that she has full and satisfactory information available for all staff employed to work at the home. 31/01/2010 To ensure that people are protected. 3 39 26 The manager must ensure 31/01/2010 that a copy of the report that is written as a result of the providers monthly Regulation 26 visit is kept at the home and is made Page 35 of 37 Care Homes for Adults (18-65 years) 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 Description Timescale for action available for inspection. To ensure that the provider is monitoring the service 4 42 23 The manager must ensure that fire drills and practices are carried out at suitable intervals. 31/01/2010 To protect the people living and working in the home. 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 42 It is recommended that the weekly fire system checks are carried out weekly to ensure that the system is safe. Care Homes for Adults (18-65 years) Page 36 of 37 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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