Inspection on 07/08/09 for Aytun Care Home

This is the latest available inspection report for this service, carried out on 7th August 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aytun Care Home 27/06/06

Aytun Care Home 22/02/06

Aytun Care Home 13/10/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 13/03/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Aytun Care Home 33 Strode Road Forest Gate London E7 0DU     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: Lea Alexander     Date: 1 0 0 8 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: Aytun Care Home 33 Strode Road Forest Gate London E7 0DU 02085556097 02085556133 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: FBP Ventures Ltd care home 3 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: 3 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 Aytun Care home is a three bed roomed house in a residential area of Forest Gate that registered to operate as a care home in January 2005. The home accommodates three adult service users with learning difficulties. The home is situated close to the local shopping facilities at Forest Gate and nearby Stratford. There is good access to public transport with train, tube and bus routes nearby. 3 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 28 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: One Inspector carried out this inspection over the course of two afternoons on Friday 7th August 2009 and Monday 10th August 2009. During the course of the inspection we reviewed the progress with requirements made at a previous inspection and also looked at the key National Minimum Standards. We spoke with the care worker on duty and with the Deputy Manager. We also spoke privately with the people who use the service. In addition we examined a range of documentation relating to the running of the home including residents personal files, staff personnel files and health and safety records. Care Homes for Adults (18-65 years) Page 5 of 28 What the care home does well: What has improved since the last inspection? What they could do better: A number of requirements are made as a result of this inspection. In order to maintain its current two star rating the service will need to address these areas of shortfall promptly and thoroughly. Individual plans must be reviewed at least every six months or as needs change. The home should develop its individual plans to include information addressing capacity and consent issues. The home must use a standardised risk assessment tool for all residents. All potential risks must be assessed and a management plan developed. All periods of self medication must be subject to a risk assessment and management plan. The home must ensure that a current MAR sheet is always available. Care Homes for Adults (18-65 years) Page 6 of 28 The home must attend to some minor repairs and plan for a programme of refurbishment. The home must ensure that the staffing roster includes all staff who will be working, including those engaged in community activities with people who use the service. The home should ensure that references received contain sufficient information. The home must evidence that a CRB check is obtained for all staff. The home must evidence that all staff receive a minimum of five days paid training each year, and that all staff undertake regular refresher and update training in core areas, such as first aid, medication, foody hygiene, moving and transferring and safeguarding. The home must improve its recording and record keeping practises in relation to residents personal files. Fire doors must not be wedged open. We also made some good practise recommendations for the home to consider: Individual plans would benefit from the inclusion of life story work. The home should consult regularly with residents on the issue of student placements within the home. The home should consider requesting all available information when carrying out CRB checks. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 28 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 28 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. Previous inspections have evidenced that the home has developed a statement of purpose that accurately describes the service being provided. Evidence: There have been no new admissions to the home since the last inspection. Care Homes for Adults (18-65 years) Page 9 of 28 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is some evidence that residents are involved in day to day decision making processes within the home. Staff are able to communicate with residents and understand their needs. Individual plans include basic information, but are not detailed and do not include life story work. Some basic risk assessments have been completed. The home consults residents about their satisfaction with the service provided. Evidence: We looked at the personal files for both the people living at the home. This evidenced that plans addressing a range of personal, healthcare and social needs had been developed for each. We noted however that these plans did not include any life story work or information relating to the residents life prior to their moving into the home. For both residents we were not able to evidence that these plans were reviewed at least every six months or as needs change. Care Homes for Adults (18-65 years) Page 10 of 28 Evidence: We spoke with people who use the service, with the deputy manager and care staff. We also looked at individual plans and records relating to finances. One resident requires assistance in managing their finances, whilst the other is independent, and this is reflected in their individual plans. The home retains monies on behalf of one resident, and they are able to access these funds as they are required. A record of each transaction indcluding the date, amount and nature of each deposit or withdrawal is maintained, and this is signed by staff. We noted that the cognitive impairment and learning difficulty experienced by residents could impact upon their ability to make decisions. However, the individual plans we saw did not address issues of capacity or consent for either resident. We spoke with residents and looked at the minutes of residents meetings. This evidenced that residents and staff meet regularly to discuss issues relating to the day to day running of the home. Issues discussed recently included daytime activities, holidays and replacement of furniture. We also noted that the issue of students on placement had been discussed and agreed with residents at a meeting in October 2007. Students continue to undertake placements at the home, however we noted that there was no evidence of subsequent discussion of this issue with residents. The home had completed risk assessments for both residents. We examined these and found that they addressed a range of activities identified in the individual plans including mobility, assistance with moving and transferring, outdoor activities and challenging behaviour. However, we noted that different risk assessment tools had been used for each resident. Whilst looking through the personal file of one resident we noted that they had gone to stay with a friend for several days. However, there was no risk assessment addressing this. The residents ability to manage their own medication during this period had also not been assessed. We also noted that the resident did not return on the agreed day, and that no managment plan to address this possibility had been developed. Further examination of records evidenced a further period of unauthorised absence from the home. However gaps in record keeping made it difficult to establish the precise length of this unauthorised absence. Care Homes for Adults (18-65 years) Page 11 of 28 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 who use the service are able to maintain personal and family relationships. Residents are involved with meaningful daytime activities that reflect their interests, needs and abilities. The menu is varied and nutritious and reflects residents preferences. Evidence: We spoke with residents and staff and also looked at individual plans and activity records. These evidenced that both residents are engaged in a range of community activities. In recent months residents have regularly visited the cinema, gone bowling and been for meals out. In addition one resident attends a community group and has completed an adult education dressmaking course. The other resident attends weekly physiotherapy sessions and trampolining classes. Residents told us that within the home they enjoyed listening to music or watching the Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: TV. Both residents are supported to maintain contact with family members. The home develops a weekly menu based on the meals that residents say they would like to eat. We looked at the record of meals provided and found that varied and nutritious meals were provided. One resident is able to prepare some of their own meals with assistance. This was reflected in their personal plan. The resident involved told us that they very much enjoyed this. Care Homes for Adults (18-65 years) Page 13 of 28 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. Personal support is responsive and varies according to the needs and preferences of the person using the service. Residents are supported to access a range of healthcare services. Evidence: One resident is independent for their personal care, the other requires assistance. We looked at their individual plan and this included information on how they prefer to receive personal care. We spoke to this resident who told us that they were happy with the way that staff helped them with personal care. We found records on both residents personal files relating to healthcare appointments. This evidenced that people who use the service are supported to access a range of services including the dentist, optician and GP. We also found evidence that staff record the outcome of these appointments with any follow up. At the time of this inspection there were no residents who were self medicating. Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: However, as noted in an earlier section of this report one resident does self medicate during periods of leave from the home. No residents were prescribed controlled drugs at the time of this inspection. We looked at the Medication Administration Records (MAR) for both residents, and the available medication. We found that the two corresponded, and that the MAR sheets was in good order. However, we noted that the available MAR sheet had run out the preceeding day, and that no new MAR sheet had been drafted. Care Homes for Adults (18-65 years) Page 15 of 28 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. Residents say that they are happy with the service provided, and that they feel safe and supported by the home. Residents understand how to make a complaint. Staff demonstrate an understanding and awareness of safeguarding issues. Evidence: We looked at the homes complaints log. This evidenced that no complaints had been received since the last inspection. We spoke to residents who told us that they had no complaints and felt safe and comfortable with staff. They also told us that they would tell the Deputy Manager or care workers if there was anything they were worried or unhappy about. We spoke with the Deputy Manager who told us that that there had been no adult protection concerns since the last inspection. We spoke with the care worker on duty. They demonstrated an understanding of the different types of abuse vulnerable adults might experience, and their responsibilities should they have any safeguarding concerns. Care Homes for Adults (18-65 years) Page 16 of 28 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 homes physical environment meets the needs of residents. People who use the service are able to personalise their rooms, and a range of shared spaces are available. However, the home would benefit from a programme of redecoration and refurbishment. Evidence: During our visit to the home we carried out an inspection of the premises. The home has an entrance hallway, and the homes registration and insurance certificates are displayed here. One residents bedroom is on the ground floor, as is the main bathroom. This has a WC, handbasin and bathtub with bath seat. The homes washing machine and a locked cupboared with cleaning materials are also located in this bathroom. To the rear of the poperty on the ground floor there is a lounge. This is decorated with pictures of residents and there is a range of comfortable seating. There is a TV with satellite programming and a stereo. Off the lounge there is a kitchen with a range of fitted units and the usual appliances. Patio doors from the kitchen give access to a small rear garden with a patio and lawned area. Access to the first floor is via stair case. The Managers office is located on this level. This is locked whilst the Manager and Deputy are not on site, and a large cupboard in the hallway is used to store documents and paperwork staff require access to at all Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: times. A small shower room with WC and handbasin is located off the landing. Two further bedrooms for residents are located on this level. A range of maintenance and repair issues were identifed as a result of this inspection, and they are detailed in the requirements section of this report. We formed the view that the home would benefit from a programme of redecoration and refurbishment During our visit to the home we found it to be clean and free from offensive odours. Care Homes for Adults (18-65 years) Page 18 of 28 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. People who use the service are satisfied with the care that they receive. There are sufficient staff numbers employed to meet the identified needs of people who use the service. The home recognises the importance of training and staff are encouraged to undertake NVQ level qualifications. However, the home must ensure that staff undertake regular update and refresher training in core areas. Evidence: At the time of this inspection the home employed five care workers. Three shifts are organised over a 24 hour period and these run from 8am to 3pm, 3pm to 10pm and 10pm to 8am. There is usually one member of care staff on duty for each shift, with the Deputy Manager in attendance during weekdays. When residents have community activities, additional care staff come on duty. We looked at the homes current rota and found that it reflected the situation we found in the home. However, the rota did not indicate when additional staff had been rostered for community activities. Waking staff cover the night shift. Staff have a handover meeting at the start of each shift. We looked at the records of these handover meetings and noted that standing items included any scheduled appointments, feedback relating to residents well being and tasks to be completed on the shift. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: All of the homes care staff have obtained NVQ level 2. Four care staff have obtained NVQ level 3,whilst the fifth care worker is currently studying for this. One of the care staff has recently obtained NVQ level 4. We examined the personnel files of three care workers. These evidenced that the home obtains references and carries out an enhanced Criminal Records Bureau (CRB) check prior to staff being employed. It also obtains proofs of identity and issues staff with copies of their employment terms and conditions. However, for one staff member we noted that the references obtained were extremely brief, and that the manager had not contacted the referees to verify them. For a second staff member whilst the personnel file indicated that a CRB check had been obtained, there was no reference number or date for this. On the CRB checks that were available we noted that the home did not routinely request background information from POCA or the Department of Education. We looked at staff training records for two care workers. We also spoke with the deputy manager and care staff. A newly joined member of staff was evidenced as having completed health and safety, moving and transferring, basic life support and safeguarding training in 2009. However, a second member of staff had not received any training in 2009. We noted that in 2008 they had completed a range of training including food hygiene, moving and transferring, first aid, health and safety and medication. The certificates issued for this training clearly state that they are valid for one year only. We noted that this time period had expired, with no evidence of refresher or update training having been provided. It was evidenced that each member of staff had completed an induction to the home. We looked at supervision records for two care staff. These evidenced that the home is on target to provide a minimum of six supervisions to staff in a twelve month period. Care Homes for Adults (18-65 years) Page 20 of 28 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 Manager and Deputy Manager are suitably qualified and experienced. The home has developed and implemented sound health and safety practises. Where ever possible residents are supported to manage their own finances. Evidence: Both the Manager and Deputy have obtained NVQ level 4, the Deputy Manager has also obtained the Registered Managers Award (RMA). The Manager is suitably qualified and experienced. The Deputy Manager advised us that feedback surveys had been distributed to people who use the service, and to healthcare professionals. The outcomes from the completed surveys had been collated we viewed this and noted that feedback was postive. The home has produced an employee handbook, this contains copies of key policies and procedures. It also contains records of each staff induction. Care Homes for Adults (18-65 years) Page 21 of 28 Evidence: We examined both residents personal files in detail during the course of the inspection and formed the view that they could be better maintained. As mentioned in an earlier section of this report, unclear recording made it difficult to establish the precise dates one resident had taken unauthorised leave from the unit. In both residents personal files we found that unrelated papers were clumped together making it difficult to locate information. In one residents file we also found papers that did not relate to them at all. We examined a range of records relating to health and safety. The home carries out weekly testing of fire alarms and records the outcomes. A fire evacuation drill occurred in July 2009. However, during our tour of the premises we did note that some fire doors had been wedged open. We also looked at the homes record of fridge and freezer temperatures. This evidenced that temperatures are tested on a daily basis and maintained within acceptable parameters. The home has obtained appropriate insurance cover. Care Homes for Adults (18-65 years) Page 22 of 28 Are there any outstanding requirements from the last inspection? Yes R 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 1 6 15 The home must evidence that individual plans are reviewed at least every six months or as needs change. The home must ensure that an up to date staffing rota that accurately reflects staffing levels within the home is available at all times. 30/01/2008 2 33 18 30/01/2008 3 35 18 The Registered Person must 30/01/2008 ensure that there is a staff training and development programme and that all staff receives a minimum of five days training per annum. The home must evidence that all staff have received manual handling initial and refresher training. Care Homes for Adults (18-65 years) Page 23 of 28 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 7 12 The home should develop its 31/03/2010 individual plans to include information addressing capacity and consent issues To promote the safety and wellbeing of people who use the service. 2 9 13 All periods of self medication 31/03/2010 must be subject to a risk assessment and management plan. To promote the safety and wellbeing of people who use the service. 3 9 13 The home must use a standardised risk assessment tool for all residents. To promote the safety and wellbeing of people who use the service. 31/03/2010 Care Homes for Adults (18-65 years) Page 24 of 28 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 4 9 13 All potential risks must be 31/03/2010 assessed and a management plan developed. To promote the safety and wellbeing of people who use the service. 5 20 13 The home must ensure that a current MAR sheet is always available. To promote the safety and wellbeing of people who use the service. 31/03/2010 6 24 13 In the kitchen missing tiles behind the cooker must be replaced. Damage to the walls by the sliding doors must be repaired. To promote the safety and wellbeing of people who use the service. 31/03/2010 7 24 13 The home must consider the 31/03/2010 layout of furniture in the lounge, particularly the seating positioned underneath the boiler. To promote the safety and wellbeing of people who use the service. 8 24 13 In the ground floor 31/03/2010 bathroom mouldy or missing grout must be replaced. The toilet seat must be secured Care Homes for Adults (18-65 years) Page 25 of 28 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 and the missing sink plug replaced. To promote the safety and wellbeing of people who use the service. 9 33 18 The home must ensure that 31/03/2010 the staffing roster includes all staff who will be working, including those engaged in community activities with people who use the service. To promote the safety and wellbeing of people who use the service. 10 34 19 The home must evidence 31/03/2010 that a CRB check is obtained for all staff. To promote the safety and wellbeing of people who use the service. 11 34 19 The home should ensure that references received contain sufficient information. To promote the safety and wellbeing of people who use the service. 12 35 18 The home must ensure that all staff undertake regular refresher and update training in core areas, such as first aid, medication, foody hygiene, moving and 31/03/2010 31/03/2010 Care Homes for Adults (18-65 years) Page 26 of 28 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 transferring and safeguarding. To promote the safety and wellbeing of people who use the service. 13 41 7 The home must improve its recording and record keeping practises in relation to residents personal files. To promote the safety and wellbeing of people who use the service. 14 42 23 Fire doors must not be wedged open. To promote the safety and wellbeing of people who use the service. 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 31/03/2010 31/03/2010 1 2 3 4 6 8 24 34 Individual plans would benefit from the inclusion of life story work. The home should consult regularly with residents on the issue of student placements within the home. The home would benefit from a programme of refurbishment and redecoration. The home should consider requesting all available information when carrying out CRB checks. Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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