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Inspection on 28/07/09 for 45 Mayfield Park North

Also see our care home review for 45 Mayfield Park North for more information

This is the latest available inspection report for this service, carried out on 28th July 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Comments received through surveys from a care coordinator that visits the home included ` Since the closure of day care services, other activities have been organised. There is good structure for day to day activities, staff work well together and have 1:1 time with people at the home.` The surveys received from people at the home indicated that sufficient information was received so that decisions about moving into the home could be made. They are able to make decisions about what to do each day, the staff treat them well and they know who to approach with complaints. Additional comments made included ` I am happy here and would rather not move` and ` I would like to tell you I am alright and happy.` People at the home confirmed that they receive a good standard of care and are respected as individuals.

What has improved since the last inspection?

Since the last inspection, the manager had reviewed the care planning process, people at the home have input into the way their care is delivered and are able to shape the way they live at the home, this shows people have personalised care.

What the care home could do better:

One requirement was made at this inspection and it was to formulate fire risk assessment. Fire risk assessments must consider the potential of fire in the premises to then develop an action plan to lower the risk of fire at the home

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 45 Mayfield Park North 45 Mayfield Park North Fishponds Bristol BS16 3NH The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sandra Jones Date: 2 9 0 7 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. 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 Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (20092008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: 45 Mayfield Park North 45 Mayfield Park North Fishponds Bristol BS16 3NH 01179583869 01179709301 i.williams10@blueyonder.co.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust care home 5 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) : Number of places (if applicable): Under 65 Over 65 5 5 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection A bit about the care home Mayfield Park North is a care home for five adults with mental health care needs. It is operated by Aspects and Milestone Trust and managed by Ioan Williams. The property has the appearance of a domestic dwelling, which blends well with its immediate environment. It is close to shops, amenities and bus routes. Arranged over three floors, with shared space on the ground floor and bedrooms on the lower ground floor and first floor. There is self- Care Homes for Adults (18-65 years) Page 4 of 30 contained accommodation on the basement that is used by a resident that is independent with living skills. Care Homes for Adults (18-65 years) Page 5 of 30 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 6 of 30 How we did our inspection: This is what the inspector did when they were at the care home This key inspection was conducted unannounced over two days in July 2009 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. Four completed Have your say surveys were received at the Commission from people who use the service. Feedback from Health and Social Care Professionals was also sought through surveys. Four people at the home and one social care professional responded. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the AQAA and notified incidences in the home, (Regulation 37s). This information was used to plan the inspection visit. The four people living at the home were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and Care Homes for Adults (18-65 years) Page 7 of 30 reviews of the care of people using the service and other related documents. The homes policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered either by face- to- face discussions or by surveys. What the care home does well Comments received through surveys from a care coordinator that visits the home included Since the closure of day care services, other activities have been organised. There is good structure for day to day activities, staff work well together and have 1:1 time with people at the home. The surveys received from people at the home indicated that sufficient information was received so that decisions about moving into the home could be made. They are able to make decisions about what to do each day, the staff treat them well and they know who to approach with complaints. Additional comments made included I am happy here and would rather not move and I would like to tell you I am alright and happy. People at the home confirmed that they receive a good standard of care and are respected as individuals. Care Homes for Adults (18-65 years) Page 8 of 30 What has got better from the last inspection What the care home could do better 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 9 of 30 If you want to speak to the inspector please contact Sandra Jones 33 Greycoat Street London SW1P 2QF 02079792000 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 10 of 30 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 11 of 30 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. Sufficient information is provided to people wishing to live at the home and there is an effective admission process for people to make choices about living at the home. Evidence: The Statement of Purpose was reviewed since the last inspection and says that the home operates under OBrien five accomplishments that include choice, independence, privacy and dignity. The aim of the home then is to enable people with mental health needs to develop fulfilling life in the community. It states that the home can offer accommodation to people with enduring metal health needs between the ages of 50- 65 years. A clear and in-depth admission criteria is listed ensuring that assessments are conducted to establish that thee needs of the people at the home can be met. There are no vacancies and the people currently accommodated have lived together for a significant period of time. Care Homes for Adults (18-65 years) Page 12 of 30 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 at the home is personalised, people at the home have input into their care plans evidencing that they have a say about the way their care is to be delivered. Evidence: Individual case files have four mains sections and incorporate information about the person, their care, health, management and finance. The manager said that ICPAs meetings are annually convened by the care coordinator with the person, psychiatrist and home manager present. Care plans are then developed following the meeting which the keyworker discusses with the person and once agreement with the action plan is reached, the person signs to evidence agreement. Comments were sought from the people at the home about the way their care needs are met. We were told that care plans are discussed with the keyworker and they sign the care plan if they agree with it and confirmed that they are able to make decisions. A member of staff on duty explained that care plans are discussed with the person and focus on the way the person leads their live and how the care is to be delivered. Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: All about information is written in the first person giving a brief description of the preferred forms of address, contact information and family and friends. All areas of the individuals life, their abilities and aspirations and wishes are also clearly described. Care plans instruct the staff on the way the individuals needs are to be met and incorporated are the individuals capabilities. It is evident that care plans are working documents which are reviewed and amended as required. Mental Capacity Statements were completed by the manager about the way individuals capacity to make decisions which health care professionals sign to confirm the statements. Risk assessments for all activities that may involve an element of risk are in place. People are assessed on their level of competency to undertake independent living skills. For example, personal care needs, staying at home alone and leaving the home without staff support. A more detailed risk assessment is then completed listing the persons ability and the support needed to maintain their level of Independence. These are reviewed and signed. Care Homes for Adults (18-65 years) Page 14 of 30 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 at the home are supported to pursue their chosen lifestyles and are part of the local community. Evidence: The manager told us that since the last inspection there has been a downward shift in the way the home operates, people have become older and the way they keep themselves occupied. We were further told that 1:1 time has increased and there is a more relaxed atmosphere. The people at the home have no structured day care services since the day care centered closed down. One person is now retired, two people no longer have day care center provision and the fourth person has made the decision not to participate in any structured day care provision. The people at the home are over retirement age and are not employed, since the closure of the day care facility, the home organises leisure activities. We were told that people at the home have 1:1 time with their keyworker at least monthly as well as ad Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: hoc activities. The culture at the home is more relaxed and activities are organised depending on the weather and wishes of the people at the home. A large plasma television was purchased because the people at the home enjoy watching television. Two people go out together for lunch each week without staff support, two are independent in the community and one must be accompanied by staff. People visit local shops, restaurants and places of interest. People at the home were asked about the activities they do during the day. People said that they trips out with their keyworker are more frequent, they are supported by the staff to undertake chores. Regarding the food, we were told that meals at the home are good. The visiting arrangements are specified within the Statement of Purpose, which states that there is open visiting, and can be conducted in private. For one person restrictions are imposed on one visitor and a risk assessment that supports this decision is in place and regularly reviewed. There is a visitors book and all visitors to the home must specify the date and nature of their visit. There is an expectation that people contribute to the running of the home and the level of participation has reduced because of the increasing age of the people accommodated and their abilities. The expectation has shifted to maintenance of personal space and undertaking household chores when and if the task is enjoyed. The way people are respected as individuals was examined during the inspection. People have lockable rooms, mails is handed unopened and house meetings are held regularly so that they can have input into the running of the home. House meetings are the forums used to make decisions while smaller issues are dealt with on a day to day basis. At the most recent house meeting, swine flu was discussed and choices about the soft furnishings were made. Staffs feedback about the way people at the home are respected as individuals. The staff said that seeking permission before undertaking tasks and ensuring that people had the equipment necessary to pursue individuals hobbies were ways they ensured the rights of the person was respected. The lounge is a smoking room and exception was sought for this space to remain a designated smoking area, an extractor and vent was provided to keep the area ventilated. The three people at the home are smokers and the fourth person has an independent flat bust chooses to socialise in the lounge. The choice of main cooked meal is made daily by the people at the home, it is now prepared by the staff and served at lunchtime. With the exception of one, people prepare their tea-time meal which is lighter than the main meal. A record of food provided is maintained and shows that people have a varied diet which they choose. The range of tinned, fresh and frozen foods stored at the home confirms that the variety and healthy food served at the home. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: Care Homes for Adults (18-65 years) Page 17 of 30 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 people are supported by the staff to manage with support their personal and health care. Evidence: The people at the home generally need prompting with personal care and where more assistance is required care plans specify the support needed by the staff. There is clear evidence that people have a say about the way their care is to be delivered. The manager said that people living at the home have more direct access to the psychiatrists through the Avon and Wiltshire Mental Health Team (AWP). Reviews are convened regularly by the care coordinator, ICPAs meetings are annual with the psychiatrists, the person and home staff. A record of routine health checks, visits to NHS facilities and health care professionals involved is maintained. It is evident that people access their GPs, visit hospitals for specialist care, dentists and opticians. Each person has a medical profile that lists the individuals needs; medication prescribed, its purpose and homely remedies. The way the medication is managed in terms of re-ordering medications is also included within the medication profiles. Individuals are able to have full control of their medication including the ordering of Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: repeat prescriptions. With the exception of one, people at the home self administer their medications. Medications administered by the staff are through a monitored dosage system and staff sign the records following administration. The arrangements for health care was discussed with the people at the home during the inspection. One person said that they are accompanied on health care visits while another said that they are able to visit the GP without staff support. Comments were sought from staff about health and personal care and we were told that one person is supported with personal care. Regarding healthcare, staff said that support is only given where it is necessary. Feedback about the way medical advise is followed was then sought. We were told that people that are independent with health care will generally pass the information from the GP to the staff which is recorded. A communication book and handovers are used to ensure that advise is followed by all staff. Care Homes for Adults (18-65 years) Page 19 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff respond to individuals concerns and complaints and are safeguarded from abuse. Evidence: The Complaints procedure is on display within the home and included in each persons file which they sign. The manager told us that each year the procedure is reviewed with the person to ensure they know who to approach with complaints. One complaint from one person at the home was logged since the last inspection and the nature and level of satisfaction is recorded. The manager also explained that more informal complaints are received through house meetings and the actions taken to resolve these complaints are recorded with the minutes of the house meetings. People at the home were consulted about complaints and protection at the home. Individuals named the person they would approach with complaints and generally they would approach their keyworker or manager. Individuals said they felt safe at the home and staff did not shout. Members of staff said that their responsibilities towards safeguarding people from abuse was to protect people and report any alleged abuse. Regarding Whist blowing, staff were clear about their responsibility to report poor practice. The Do the right thing Whistleable policy emphasis a commitment to supporting staff who come forward to report and express concerns about practices at the home. IT further says that failure to report poor practice may be involved in disciplinary. Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: There are no outstanding safeguarding adults referrals. Care Homes for Adults (18-65 years) Page 21 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people at the home live in a homely environment that meets their needs. Evidence: The property has the appearance of a domestic dwelling with level access into the home. It provides accommodation and personal care for four people, arranged over four floors with shared space on the ground floor and bedrooms on the basement and first floor. The third floor is used by staff for sleeping-ins at night. There is a bed-sit, with en-suite on the basement, used by one person living independently. On the first floor there is a double and single room. The property is close to the local shops and bus routes Overall the building is maintained to an adequate standard and clean and since the last inspection,new lounge furniture and large plasma television was purchased. There are plans to refurbish bedrooms to ensure individuals, have a homely environment. The bed-sit in the basement is fully fitted with en-suite, kitchen, sitting and sleeping space. On the first floor there are two bedrooms, shared by two females and one bedroom. Both bedrooms contained a combination of the homes furniture and individuals personal belongings reflecting their lifestyles. There is a lounge with sufficient seating for four people, a dining room with additional seating and kitchen providing sufficient shared space to sit together and away from others. Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: The laundry space is adjacent to the kitchen, with floors and walls that can be easily washable. There is a washing machine and tumble dryer that are domestic in scale. The washing machine is designed to reach 90 temperature. Care Homes for Adults (18-65 years) Page 23 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team are qualified and competent to meet the stated purpose of the home and the assessed needs of the people living at the home. Staff would benefit from regular individuals supervision. Evidence: Staff records are held centrally at the Trust office and a letter confirming that Criminal Record Bureau (CRB) checks were obtained and clear is provided. For bank staff the manager is provided with CRB serial numbers to confirm that the staff are able to work with vulnerable adults. The staff team are currently undertaking refresher statutory training in First Aid, Food Hygiene, Safeguarding Adults, Medication Foundation and Moving and Handling. The arrangements for training was discussed with the manager who told us that the training provided is relevant to the individuals range of needs. For example mental health awareness training is provided to all staff while diabetes training is provided to the keyworkers of those individuals who are diabetics. Mental Capacity Act and Deprivation of Liberty Safeguards training was attended by the manager to be cascaded to all staff. This will ensure that the home operates from a multi agency approach. People at the home were asked about the skills of the staff working at the home. Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: Comments made include staff are OK and staff know what my needs are. Staff told us that training is provided and encouraged by the manager and the purpose of specific training in mental health awareness s to increase insight. This training has enabled staff to make decisions following assessments the individuals level of competency. The staff team is small and generally issues are addressed as they arise. Appraisals took place in February and the two staff are undertaking NVQ level 3 are have more regular supervision. The manager acknowledged during the discussion that supervision needs to be more regular. Staff said that individuals supervision is from the manager where concerns and suggestions are freely discussed. Care Homes for Adults (18-65 years) Page 25 of 30 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. Policies, procedures and practices meet the homes stated purpose and objectives and needs of the people at the home. People at the home benefit from ongoing monitoring of the standards of care. Evidence: The way the homes aims and objectives are met was discussed with the manager who said that maintaining a homely atmosphere where people feel safe is the priority of the home. People at the home have a tendency to worry and the stable team are able to keep the home calm for them. As the individuals become older their needs change which means the atmosphere must reflect their changing needs. The systems that ensure consistency are through handovers, line management supervisions and meetings. The Trust operates a Quality Assurance system, people complete in-house surveys where they rate all areas with an external facilitator visiting to seek their views. Peers audits are done by the managers with specific knowledge in the range of needs of the home and they will feedback on any gaps identified. Staff are also involved and complete 360 degree feedback about the manager which is sent directly to the Trust to formulate a report. An action plan is then formulated, AQAA and Business plans are Care Homes for Adults (18-65 years) Page 26 of 30 Evidence: used to inform the future of the home. The rota in place shows that one member of staff is on duty throughout the day, with an additional member of staff rostered to provide 1:1 support and one person sleeping on the premises. The manager ensures that the home complies with associated Health & Safety legislations. External contractors are used to conduct audits, the Gas boiler is new and under guarantee and portable equipment checks are conducted annually. While fire systems checks and practices occur as recommended, fire risk assessments are not in place. Fire risk assessments that assess the potential of fire in the premises must be completed to ensure action to lower the level of risk is taken. Care Homes for Adults (18-65 years) Page 27 of 30 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 28 of 30 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 42 23 02/10/2009 The manager must take adequate precautions against the risk of fire. Fire risk assessments that considers the potential of fire in the home including preventative measures must be developed. 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 29 of 30 Helpline: Telephone: 03000 616161 or Textphone : or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!