Inspection on 16/06/10 for Athelstan House

This is the latest available inspection report for this service, carried out on 16th June 2010.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Athelstan House 17/07/08

Athelstan House 11/09/07

Athelstan House 22/11/06

Athelstan House 27/04/06

Athelstan House 13/12/05

Athelstan House 21/02/05

Athelstan House 13/08/04

Similar services:

Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Key inspection report Care homes for adults (18-65 years) Name: Address: Athelstan House 42 Hanworth Road Feltham Middlesex TW13 5AY     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: Simon Smith     Date: 1 6 0 6 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 30 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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: Athelstan House 42 Hanworth Road Feltham Middlesex TW13 5AY 02085815576 02085815576 athelstan.house@blueyonder.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Rosemary Wairimu Harrington,Mr Paul Martin Harrington Name of registered manager (if applicable) Mr Kelvin Ithiga Type of registration: Number of places registered: care home 5 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 5 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home Athelstan House is a registered care home for a maximum of five adults with learning disabilities. It is privately owned by Mr and Mrs Harrington, the registered providers. Mr and Mrs Harrington are not involved in the day-to-day running of the home but have appointed a manager, who has applied for registration with CQC. 5 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 30 Brief description of the care home The home is situated on a busy residential street close to local shops and public transport networks. There are two bedrooms on the ground floor and three on the first floor of the house. All the bedrooms have en suite toilet facilities. There are also shared bathroom facilities on each floor. The communal rooms include a lounge/dining area, separate lounge and kitchen. There is a well-maintained garden at the rear of the home. Fees range from £950 to £1700 per week. 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 peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is two stars. This means the people who use this service experience good quality outcomes. We used information from a range of sources when making this judgement about the home. This included visiting the home unannounced on 16 June 2010 and meeting the manager, a member of staff and people who live at the home. We also spoke to two of residents friends/relatives by telephone. We checked some written records including residents care plans, staff files and health and safety checks. We also took into account any information about the home we have received since the last inspection. This included notifications of any accidents, incidents, complaints or safeguarding alerts. The manager submitted an AQAA in March 2010. The AQAA is a quality assurance self-assessment, which gives us information about the home in the last year. We met both the people who live at the home. One resident told us that he is happy with his accommodation and the support he gets from staff. He also told us that he can choose how he spends his time and that he has privacy when he wants it. The resident said he couldnt think of anything he Care Homes for Adults (18-65 years) Page 6 of 30 would like the home to do better. Both the friends/relatives we spoke to said that they were satisfied overall with the support their friend/relative receives at the home. Comments made by relatives included: Im happy with the service Im very happy overall Theyre very caring The home always seems clean and tidy They get in touch with me regularly. They always get in touch if theres a problem The friends/relatives we spoke to felt that the service provided by the home had improved in the last twelve months. One friend/relative said she felt the attitude and approach of staff had improved and that the home now communicated more effectively with her. Another friend/relative said that the home keeps her more up to date with events affecting her friend/relative than in the past. Friends/relatives also identified an area in which they felt the home could improve. Both the friends/relatives we spoke to felt that their friends/relatives could be encouraged and supported to participate more in organised activities in order to develop their social networks and increase their skills. Care Homes for Adults (18-65 years) Page 7 of 30 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. Care Homes for Adults (18-65 years) Page 8 of 30 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 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 10 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. The provider has produced clear information about the home and the services it provides. Residents needs and strengths are assessed before they move into the home. Prospective residents can visit and stay at the home before deciding to move in. Evidence: The provider has produced a Statement of Purpose and service user guide for the home. These documents explain the serviceS the home provides and set out residents rights and responsibilities. The Service User Guide is available to all current and prospective residents. It contains details of the accommodation, including photographs of the home, and information about the staff who work there. We saw evidence that residents needs are assessed by their placing authority before they move into the home. The manager said that residents are encouraged to visit the Care Homes for Adults (18-65 years) Page 11 of 30 Evidence: home before deciding to move in and that residents move in initially on a trial basis. 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. Each resident has an individual care plan, which is reviewed regularly. Residents are able to choose how they spend their time and to choose who attends meetings at which their care is discussed. Risk assessments are carried out where necessary but these need to be reviewed regularly to take account of changes in need or circumstances. Evidence: We found evidence that each resident has an individual care plan. Care plans identify residents strengths and support needs in important areas such as personal care, social/emotional/cultural needs, mental health, medication, mobility and communication. We found that care plans are reviewed in-house on a monthly basis and that these reviews assess progress towards goals identified in the care plan. We also found evidence that residents placing authorities review their placements Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: annually. The reviews on file were attended by the home manager, local authority care manager, resident and next of kin. We found evidence that residents are able to choose how they spend their time each day. The home seeks the input of other relevant people when residents are considering important decisions, such as next-of-kin, family members or health professionals. Residents are able to choose who they want to attend their reviews and other meetings at which their care is discussed. Residents care plans contained risk assessments where necessary. The assessments addressed potential risks to residents in their everyday lives and identified control measures that staff can put in place to minimise these risks. Some of the risk assessments we saw had not been reviewed for some time. The home must ensure that risk assessments are reviewed regularly to take account of changes in need or circumstances. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can see their friends and families whenever they wish. The home should consider how staff can proactively support residents to take part in activities that they enjoy and that expand their social networks and/or develop their skills. The home should work more closely with residents when planning the menu to make sure that it better reflects their preferences. Evidence: We found evidence that residents have regular contact with their friends and families. Relatives and friends that we spoke to said that they can visit residents at the home whenever they wish and that they can do so in private. Residents friends and relatives suggested that the home could do more to encourage and support residents Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: to try new things and to take advantage of activities that expand their social networks and/or develop their skills. The home should consider how they can best support residents to develop friendships and/or new skills. There is an activity plan for one resident that lists a range of activities he is supported to take part in, such as bowling, the cinema and trips to cafes and places of interest. However the daily notes we saw indicated that he often does not take part in the activities listed on the plan. The manager said that this is because the resident often chooses not to take part in the activity planned for that day. Whilst it is right that the home adopts a flexible approach that promotes residents choices, the manager must ensure that residents are supported to take part in the activities identified in their individual plans wherever possible. We asked residents and staff about the opportunities the home provides for residents to take holidays. One resident told us that he does not wish to take a holiday. The manager said that another resident has expressed a wish to visit India on holiday. The resident should be supported by the home to pursue this ambition. Care staff cook and prepare food, which is appropriate given the siz eof the home. There is a weekly menu, which is planned in advance. The manager said that residents can have alternatives if they do not like what is on the menu. Staff said that residents are asked what they would like to see on the menu but we did find evidence that the menu currently reflects residents prefences. For example one resident is Indian and particularly enjoys Asian food yet this does not appear on the menu. The home should work more closely with residents when planning the menu to make sure that it better reflects their preferences. The last inspection report made a requirement that the home use more fresh food. We found that there was not a great deal of fresh food in the kitchen at the time of this visit, although a member of staff did arrive with fresh vegetables during the afternoon. The home should ensure that the menu is based on fresh, rather than frozen, food. Care Homes for Adults (18-65 years) Page 16 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. Residents see healthcare professionals when they need to. The home keeps appropriate records of residents healthcare appointments and any treatment they receive. The home must obtain suitable storage for medication. Staff must ensure that there is no ambiguity when signing medication administration records. Evidence: Residents care plans identify their individual support needs in important areas such as personal care, social/emotional/cultural needs, mental health, medication, mobility and communication. There was evidence that residents see healthcare professionals, such as their GP, dentist, optician and community nurse, when they need to. All medical appointments and their outcomes are recorded on residents care plans. Care notes also demonstrated that residents have access to specialist healthcare professionals, such as a psychiatrist, community psychiatric nurse and epilepsy Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: specialist, through the local community team. One resident had an epilepsy review with a healthcare professional on the day of inspection. We checked the homes arrangements for storing and administering medication. We found that medication is currently stored in a filing cabinet. This must be replaced with a metal medication cabinet that meets Royal Pharmaceutical Society guidelines. We checked medication administration records for both residents. We found no errors but noted that one member of staff signs to record having given medication using the single initial B. The member of staff must sign using both initials as the letter B on a medication administration record indicates that the resident was unable to take the medication due to sickness. Care Homes for Adults (18-65 years) Page 18 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. Staff are trained in the recognition, prevention and reporting of abuse. The home has appropriate procedures for dealing with any complaints. Evidence: The local authority safeguarding policy is kept on file at the home. This sets out the procedures to be followed in the event of an allegation of abuse. Staff files contained evidence that all staff have attended Protection of Vulnerable Adults training provided by the local authority. The home has a written complaints procedure, which is included in the Statement of Purpose and Service User Guide. The manager confirmed that there have been no complaints about the home or referrals to the local authority under safeguarding vulnerable adults procedures since the last inspection. Care Homes for Adults (18-65 years) Page 19 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and tidy at the time of our visit. The home provides residents with adequate communal space but the arrangements regarding the smoking area will need to be reviewed should the home admit more residents. Residents can personalise their bedrooms as they wish. There are enough toilets and bathrooms to meet residents needs. Evidence: The home is situated on a busy road close to local shops and public transport networks. On the ground floor the home has a large entrance hall and a lounge/dining area which leads to the kitchen. There is also a separate lounge, which is currently the designated smoking area. Whilst this arrangement works satisfactorily with the two people who currently live there, it will need to be reviewed should the home admit more residents as there will be a need for more non-smoking areas. There are two residents bedrooms on the ground floor and three on the first floor. All Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: bedrooms have en suite toilet and basin. The residents we spoke to said they were happy with their accommodation. One of the residents allowed us to see his room. We found that the room was personalised to reflect the residents tastes and interests and contained family photographs and personal items. There is a shared bathroom and shower room on the ground floor and a shared bathroom on the first floor. The staff office is situated on the first floor. As the home currently has spare bedrooms, one of these is used as the staff sleep in room. Suitable staff sleep in accommodation will need to be provided if the home becomes full. We found that the home was clean and tidy at the time of our visit. The furniture provided is basic but functional and the home is adequately decorated. The home has a good-sized rear garden which was attractive and well maintained. A window frame at the rear of the building needed repair. Care Homes for Adults (18-65 years) Page 21 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered provider must ensure that there are enough staff available to cover vacant shifts and that staff do not work too many hours. Two written references must be obtained for all staff employed in the future. Staff have training in core areas and access to NVQ training. The manager must arrange one-to-one supervision sessions with each member of staff a minimum of six times a year. Evidence: The manager said that he works from Monday to Friday and that there is one member of care staff on duty with him at any time. One member of staff sleeps in at the home each night. We checked the staff rota in the office. This showed that one member of staff was working six days in the week of our inspection, three of which were very long days to cover for the absence of another member of care staff. This is not acceptable, as residents safety could be compromised if they are being supported by staff who are working too many hours. The manager explained that there are only three members of staff employed at present as the home has two residents. The registered provider must ensure that there are enough staff available to cover shifts Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: which are vacant due to sickness, holidays or other absences. The provider must also make sure that staff do not work so many hours that they are not able to perform at their best. We checked the files of all three staff. All contained proof of identity, such as passport or birth certificate, evidence of POVAFirst check and Criminal Records Bureau disclosure. Two of the files contained only one written reference. Two written references must be obtained for all staff employed in the future. Staff files contained evidence of training in core areas including food hygiene, fire safety, medication, infection control, first aid and the Protection of Vulnerable Adults. The manager said both support workers are working towards the NVQ level 2 award. The manager said that he has had one individual supervision session with one member of staff this year and no supervision sessions with the other member of staff. To meet minimum standards, the manager must arrange one-to-one supervision sessions with each member of staff a minimum of six times a year. This is to make sure that staff are supported in their jobs and have the opportunity to discuss their role and any training needs. Care Homes for Adults (18-65 years) Page 23 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. The home now has a full-time manager, who is studying towards an appropriate qualification. The manager needs to complete his registration with the CQC. The home seeks the views of residents and other relevant people about the care it provides. The home carries out health and safety checks as necessary but must make sure that any improvements identified through these checks are carried out. Evidence: The last inspection report recorded that the home did not have a full-time manager. We found that the home now has a full-time manager, which is a positive step, but that he had not applied for registration with CQC at the time of our visit. Since the inspection the manager has told us that he applied for registration. The manager told us that he is working towards the Leadership and Management in Care award (a requirement for a registered manager) and that he has the support of a mentor from Care Homes for Adults (18-65 years) Page 24 of 30 Evidence: the registered manager of another service. We saw evidence that the home distributes questionnaires to residents and their families to seek their views about the service the home provides. The most recent questionnaires were returned in April 2010. All the relatives who returned questionnaires were happy with the support their family member receives at the home. Some questionnaires also identified things they would like the home to do better. It is important that the home considers how they can make the improvements identified in the returned questionnaires. Monthly monitoring visits are carried out monthly by an adviser appointed by the registered providers. The home has an appropriate fire alarm system. Smoke detectors have been installed in all bedrooms and in communal areas. We saw evidence that the fire alarm system is tested weekly using different call points. We also saw evidence that an engineer tested the fire alarm system and emergency lighting system in April 2010 and that the homes fire-fighting equipment was tested by an engineer in December 2009. The last fire drill took place in June 2010. The homes boiler was checked in February 2010 and electrical appliances checked in August 2009. The landlords gas safety record was issued in October 2009 and the five-year electrical installation was issued in September 2005. The employers liability insurance is valid until August 2010. The home commissioned an assessment of the water system in March 2010. This assessment identified a number of actions the provider should take to ensure that the water system is safe. The provider must ensure that the necessary actions identified in the consultants report are carried out. Care Homes for Adults (18-65 years) Page 25 of 30 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 26 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 Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Ensure that risk assessments are reviewed regularly to take account of changes in circumstances. 30/07/2010 2 12 16 Ensure that residents are 30/07/2010 supported to take part in the activities identified in their individual plans wherever possible. Support residents to take an 29/10/2010 annual holiday of their choice. Ensure that the menu is based on fresh, rather than frozen, food. 30/07/2010 3 14 16 4 16 16 5 17 16 Ensure that residents are 30/07/2010 consulted about the menu so that it better reflects their preferences. Care Homes for Adults (18-65 years) Page 27 of 30 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 6 20 13 Staff must use both initials when signing to record giving medication to avoid ambiguity. 12/07/2010 7 20 13 Medication must be stored in 30/07/2010 a cabinet that meets Royal Pharmaceutical Society guidelines. Repair the damaged window frame at the rear of the home. Ensure that there are enough staff available to cover vacant shifts and that staff do not work too many hours. Obtain two written references for all staff employed in the future. Ensure that all staff have one-to-one supervision with their nmanager at least six times a year. 30/07/2010 8 24 23 9 33 18 30/07/2010 10 34 19 30/07/2010 11 36 12 30/07/2010 12 37 8 The manager must complete 31/08/2010 his registration with the CQC. Care Homes for Adults (18-65 years) Page 28 of 30 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 13 42 13 The provider must ensure that the improvements identified in the assessment of the water system are carried out. 30/07/2010 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 13 Consider how staff can proactively support residents to take part in activities that they enjoy and that expand their social networks and/or develop their skills. Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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