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Inspection on 23/02/09 for 26 Shakespeare Road

Also see our care home review for 26 Shakespeare Road for more information

This inspection was carried out on 23rd February 2009.

CSCI found this care home to be providing an Adequate 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.

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

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 26 Shakespeare Road 26 Shakespeare Road Worthing West Sussex BN11 4AS     The quality rating for this care home is:   one star adequate 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: Lesley Webb     Date: 2 3 0 2 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. 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. 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 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) 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. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: 26 Shakespeare Road 26 Shakespeare Road Worthing West Sussex BN11 4AS 01903230029 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) : psmith@sussexoakleaf.org.uk Sussex Oakleaf Housing Association Ltd care home 8 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: 8 The maximum number of service users to be accommodated is 8. The registered person may provide the following category/ies of service only: Care home only ? (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia (MD) Date of last inspection Brief description of the care home 26 Shakespeare Road is a care home registered to provide accommodation and personal care for up to eight persons with mental disorders who are between eighteen and sixty five years of age. The registration allows for one of the eight service users to be over the age of sixty-five. The service is provided by The Sussex Oakleaf Housing Association Ltd for whom the Responsible Individual is Mrs Tracey Faraday-Drake. The registered manager in charge of the day-to-day running of the home is Ms Philippa Smith. The property consists of a large semi-detached house in a residential area of Worthing Care Homes for Adults (18-65 years) Page 4 of 29 Brief description of the care home with local shops and other amenities such as the seafront and beach within easy walking distance. Specific information regarding the current range of fees charged for living at the home was availible to us at our inspection. The registered manager said that she would obtain this information and forward to us. Care Homes for Adults (18-65 years) Page 5 of 29 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: one star adequate 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: We carried out this key inspection over one day. The home did not know in advance we would be visiting. During the inspection we spent time talking to residents, the registered manager and staff. We also examined care, staff, health and safety and other documentation maintained in the home. Prior to our inspection the home completed its Annual Quality Assurance Assessment (AQAA) and returned this to us. Two residents questionnaires were also completed and returned to us. We undertook an Annual Service Review (ASR) of this home in August 2008. Care Homes for Adults (18-65 years) Page 6 of 29 Information from all the above sources was assessed and used when forming judgements on the quality of service residents receive. It was also used to determine if the home is complying with the Care Home Regulations 2001 and the National Minimum Standards for Younger People. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 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 9 of 29 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. Pre admission policies and procedures ensure prospective residents needs are identified before a decision is made whether the home is suitable for them. Evidence: There have been no new admissions to the home since 2006. We viewed the homes admission policies. These give instructions to undertake a full assessment of needs prior to prospective residents moving into the home. Previous inspections found that assessments have been completed for new residents and comprehensive information obtained including a Care Management Assessment and relevant health reports. Prior to our inspection we received two questionnaires completed by residents. Both state they were asked if they wanted to move to the home. Care Homes for Adults (18-65 years) Page 10 of 29 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. Residents are involved in decisions about their lives, and play an active role in planning the care and support they receive. Care plans are not being regularly reviewed. This means staff may not have the most up to date information needed to support individuals. Residents are supported to take risks as part of an independent lifestyle. Evidence: We examined the care records of three residents, indirectly observed practises and spoke to staff and management, finding evidence that the care people receive is based on their individual needs. For example files sampled contained plans for a range of needs including mental health, physical wellbeing, social and daily living. Residents had signed their care plans, which demonstrates their involvement in the care planning process. Improvements must be made with regard to the reviewing of care plans. For example one residents mental health care plan dated 18.02.09 states their medication has changed but their medication care plan dated 27.12.05 has not been reviewed to Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: reflect this change. Another residents financial care plan dated 05.07.07 states that three pound pocket money is to be given per day. Their income and expenditure sheet details this has increased to five pounds on some days. We discussed with the registered manager the need to ensure care plans are regularly reviewed and updated to contain accurate information. She agreed work is required in this area. Each resident is allocated a link worker. Staff that were spoken to demonstrated a good understanding of this role and the needs of people they support. For example one person explained this involves regularly meeting with the resident, going through care plans and discussing changes, offering support and motivation. Observations during our visit confirm that residents are encouraged to make decisions about their day to day lives. Residents were seen choosing what to eat at breakfast and lunchtime, what time to rise and whether to go out in the community. Regular residents meetings take place. Minutes of these evidence residents are supported to make decisions about health and safety, meals, the environment and activities. Two residents questionnaires were completed and sent to us before our inspection. Both state they always make decisions about what they do each day, and can do what they want during the day, evening and at weekends. An additional comment was recorded, absolutely happy because I do what I want. Risk assessments were seen to be in place for a number of personal risk areas for residents. Care Homes for Adults (18-65 years) Page 12 of 29 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. Residents are able to make choices about their life style, and in the main supported to develop their life skills. Generally social, educational, cultural and recreational activities meet individuals expectations. Evidence: The homes Annual Quality Assurance Assessment (AQAA) sent to us prior to our visit gives information about how residents are supported to lead fulfilling lives. For example it states Promote and support residents to maintain contact with family and friends, provide a healthy menu choice, ensure escorts for weekly visits to hairdressers and nail bar, plan individual activities with residents, group outings offered to residents, in-house activities e.g. carpet bowls, bingo, board games,celebrate individual birthdays, involve all in Christmas preparation and celebrations. Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: We examined the records of three residents, observed practises, talked to residents, staff and management and found in the main information contained in the homes AQAA to accurately reflect practises within the home. For example some residents were observed going out in the community, another was at a day placement and others were seen preparing their own breakfast and lunch. We looked at the care records for three residents, all of which included a weekly planner. In the main these detail life skills such as laundry, preparing meals and personal care. One contained social activities including going out for a meal and shopping. None contained activities such as group activities and in house activities as described in the homes AQAA. Another residents planner did not detail any events of a evening or weekend. We discussed this with the registered manager who informed us staff currently record activities in various records. She agreed the recording system would benefit from being reviewed in order that effective monitoring can take place. As at the previous inspection staff support residents to maintain contact with their families and friends so that they can maintain and develop relationships outside of the home. This includes supporting one resident to write letters and another to make phone calls and arrange visits. Residents are encouraged to make their own breakfasts and lunches, with the main evening meal being prepared by staff, with support of residents if they wish. There are three flats that form part of this service, each with its own kitchen area. We asked staff if residents who live in these plan, prepare and cook their own meals. We were informed that generally they do not. We discussed this with the registered manager who informed us the home is looking to promote residents skills further in this area by encouraging and supporting them to use their own kitchen facilities. Care Homes for Adults (18-65 years) Page 14 of 29 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. In the main the health and personal care that residents receive is based on their individual needs. Care planning systems do not always ensure effective monitoring of residents needs. The principles of respect, dignity and privacy are put into practise. Evidence: Efforts are made to promote the dignity and Independence of residents. For example a member of staff was observed encouraging a resident to wear appropriate clothing when going out in the community and continence aids have been obtained for another with specified needs in this area. We found evidence that residents are supported with the health needs. For example all three of the residents files we examined contained care plans for the management of specific health needs and evidence of external professionals involvement. One residents physical health care plan states that their are concerns with their weight. When we discussed this with the registered manager she informed us this was no longer the case. As already mentioned in the care planning section of this report work must be undertaken to ensure care plans and associated documentation are reviewed Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: on a regular basis. The records of one resident inform that they are diabetic. A care plan is on file regarding this. Guidelines for staff are maintained separately from the care plan. These include the safe blood sugar ranges and action that should be taken if levels do not fall within those specified. We looked at the record maintained of blood sugar levels, with some recordings indicating these at time had been above those recommended. The registered manager could not produce evidence that the General Practitioner had been contacted each time this has occurred (as stated in the guidelines). She agreed the current recording system needs reviewing. Evidence was found that residents are supported to access a variety of health care specialists including community psychiatrist nurses, psychologists and general practitioners. Improvements are needed with regards to recording all health care appointments. A health care appointment recording sheet was found to be in place on all three residents files we examined. The last entry for one was January 2008 and for another February 2007. By looking in daily logs, review records and letters maintained on residents files we were able to confirm residents have attended health related appointments after the dates recorded on the appointment recording sheet, however the registered manager agreed improvements are required with recording in order that effective monitoring of residents needs can be undertaken. A care plan for one resident states that they must have regular chiropody treatment. We could find no record of this taking place. We examined the medication and records of three residents, with all being stored correctly along with accurate records being in place. The home currently does not monitor the temperature within either the medication cabinent or fridge. The registered manager agreed to action this immediately. Staff receive medication training and competency assessments are carried out to ensure their practises reflect knowledge gained through training. We discussed CSCI guidance with regards to competency assessments with the registered manager who said she would obtain the guidance and implement this. Care Homes for Adults (18-65 years) Page 16 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to express their concerns and have access to a robust, effective complaints procedure. Procedures are in place that offer safeguards to residents. Staff are not trained in safeguarding and do not have sufficient knowledge to offer protection to residents. Evidence: The home has a complaints procedure which we saw on display at the entrance of the home. We viewed the record of complaints and found these to include detailed records of not only the complaint but of the investigation and outcome. There has been one complaint registered with the home in the past twelve months. This was was dealt with appropriately within agreed timescales. The registered manager gave us a book to view, explaining this is used by residents to record informal concerns. The contents of this do not substantiate this comment, with records for the past twelve months being communication between staff and one resident. She informed us this was being used by mistake and said she would ensure action is taken to inform staff of its purpose. Two residents questionnaires were completed and returned to us before our Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: inspection. Both confirm they know who to speak to if not happy and how to make a complaint. As at the last inspection a copy of the West Sussex Adult protection procedures was seen to be available to staff and residents. On the day of our inspection neither of the two members of staff on duty during the morning could confirm they have received safeguarding training. Their responses to questions asked about safeguarding indicate the need for training to be arranged. Training records for the registered manager also show that she has not undertaken training in this area. Some residents are supported by the home to manage their finances. As already mentioned in the care planning section of this report improvements are needed to ensure care plans are reviewed on a regular basis and contain up to date information. This also applies to financial care plans. For example one person states they are to have three pounds per day but their income and expenditure records detail amounts of three and five pounds being given. Care Homes for Adults (18-65 years) Page 18 of 29 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. Generally the physical design and layout of the home enables residents to live in a comfortable environment. Evidence: During our inspection we viewed all communal areas and one bedroom of a resident. All areas were seen to be homely, clean and tidy. Residents have keys to their doors so that they can choose to lock their room when unoccupied. The registered manager informed us that since our last inspection communal areas have been redecorated and flooring and work surfaces replaced in the kitchen. No odours were detected on the day of our inspection. We noted that there was no hot running water in the staff bathroom located on the top floor of the building. The registered manager informed us that a plumber had been out and needed to visit again. The maintenance book states that this visit occurred 12.09.08. We informed the registered manager that action should be taken to address this as a matter of priority due to the potential infection control risk. She agreed. Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: The maintenance book also states that uneven and unbalanced paving on paths around the service were identified 11.12.08. On 11.02.09 a quote is recorded as being obtained and a date for work will be confirmed. The registered manager confirmed the paving has not been addressed and that a risk assessment was not in place regarding this. She agreed to take action as a matter of priority due to the potential health and safety risk. Care Homes for Adults (18-65 years) Page 20 of 29 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. Staff are deployed in sufficient numbers to meet the needs of residents. Monitoring systems do not ensure sufficient numbers of staff are trained to support residents at all times. In the main recruitment practises offer protection to residents. Evidence: Staff observed during our visit appear to have positive relationships with the residents they support. For example they were seen to be patient and attentive. Staff spoken to were knowledgeable about the residents needs and appeared interested in their work. Two residents questionnaires were completed and returned to us prior to our inspection. Both state staff always treat them well,listen and act on what they say. There are currently eight people living at the home. The registered manager informed us that the home deploys two staff on early and late shifts Mondays, Tuesdays, Thursdays and Fridays. On Wednesdays, Saturdays and Sundays there is one member of staff on each early and late shift and a flexi who works from 11am to 6.30pm. In addition to this the registered manager works five days per week. At night there is one wake night worker. No separate ancillary staff are employed. The registered manager informed us that five of the residents go out by themselves independently and stated Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: that she feels the staffing levels meet residents needs. The home currently as two staff vacancies (one a 15 hour post and the other a 37.5 hour post). The registered manager informed us these are being covered by permanent staff undertaking overtime and by bank workers employed by the organisation. When examining staff rotas we saw that the registered manager is also undertaking care shifts when needed. We noted that the manager records f on the rota when undertaking shifts. She explained that this can be a mixture of management and care hours. She agreed to record specifically what hours are management and what care in order that records are accurate. We examined the recruitment records of the three newest people to start working at the home and found in the main they contained the required information to protect residents. This information included two references (obtained prior to commencing employment), full application forms and Criminal Record Bureau disclosures (CRB). One included two forms of identification, two did not. None contained evidence of a POVA first. However none of the staff had commenced employment before the home had obtained the CRB disclosure. We also noted that one persons CRB was dated 29.01.04. When this was issued the Protection of Vulnerable Adults Register was not in operation. We discussed this with the registered manager who said she would make arrangements for a new CRB disclosure to be obtained. Records confirm staff working at the home have received an induction. There was evidence that staff have received training in areas such as food hygiene, first aid and manual handling, health and safety and safeguarding adults, in addition to training on mental health. When asked what proportions of staff have received training in these areas, when this took place and how the home ensures suitable numbers of qualified staff are on duty on each shift the registered manager informed us we would have to look through each persons certificates to obtain this information. She informed us that she monitors training through staffs individual personal development plans and reviews at monthly supervision. We spoke to the two members of staff on the morning shift and examined training records. Neither hold a National Vocational Qualification (NVQ) or could confirm they have undertaken moving and handling, safeguarding, first aid or food hygiene training. Also we looked at the training records for the staff who work by themselves at night. Again neither contained evidence of a NVQ qualification. Also neither contained evidence of up to date moving and handling, one has not undertaken first aid and the other held a out of date food hygiene certificate. Both contained up to date certificates for fire safety and one certificates for challenging behaviour, protection of vulnerable Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: adults, mental health and lone working. We asked the registered manager if a qualified first aider is allocated to each shift. She said that she did not think so. We asked if a risk assessment has been completed with regard to first aid and the needs of residents. We were informed it has not. We directed the registered manager to the CSCI website where further information regarding this can be found. As already mentioned earlier in this report staff have not received training with regard to diabetes. Two residents currently have identified needs in this area. Care Homes for Adults (18-65 years) Page 23 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management of this home is not meeting the needs of residents safely with regard to the reviewing of care plans and staff training. Quality monitoring systems are in place that allow the home to measure if it is achieving its aims and objectives. In the main residents and staffs health, safety and welfare is promoted and protected. Evidence: Ms Philippa Smith, the registered manager was present throughout our inspection. She has been managing the home since March 2008 and was registered with the commission in July 2008. The registered manager hold a NVQ level 4 in health and social care and has undertaken short courses including infection control, psychosis, health and safety and risk assessment. Her training file did not contain an up to date moving and handling certificate or a certificate for safeguarding. Ms Smith informed us that she has been making enquiries with regard to the Registered Managers Award but as yet has no planned date to start this. When giving feedback to the registered manager with regard to our inspection findings Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: we instructed that work must be undertaken with regard to the reviewing of care planning documentation and staff training. She agreed these would be prioritised. Staff that we spoke to informed us that the registered manager is approachable and listens. The home has quality monitoring tools that include audits for various aspects of the service. We were shown audits for staff dated April 2008 and residents needs dated May 2008. Monthly reports in line with Regulation 26 of the Care Home Regulations 2001 were seen to be in place. We found that the residents and staff are able to discuss all aspects of the running of the home generally or on a personal level. This opportunity is offered in residents and staff meetings. The home supplied its Annual Quality Assurance Assessment (AQAA) to us prior to our inspection. We discussed the contents of this with the registered manager as this did not include information about some Key National Minimum Standards. She agreed to ensure this was completed in greater detail when next requested. We sampled a number of health and safety records. Those for electrical items, gas and wiring of the home were up to date. As already mentioned in other sections of this report action is needed to ensure pathways around the home are safe, hot water is available for staff to wash their hands in the staff bathroom and sufficient numbers of staff require training in moving and handling, first aid and food hygiene. Care Homes for Adults (18-65 years) Page 25 of 29 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 29 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 6 15 In line with Regulation 15(2)(b) the registered person must ensure care plans are reviewed on a regular basis. This must happen to ensure staff have accurate and up to date information to support residents and meet their needs safely. 23/04/2009 2 32 18 In line with Regulation 18(1)(a)The registered person must ensure that clear systems are in place, including records, that monitor suitable numbers of qualified staff are on shift at all times. This must happen to ensure the needs of residents are met safely. 23/04/2009 3 35 18 In line with Regulation 18(c) 23/05/2009 the registered person must ensure staff including the registered manager have mandatory training and Page 27 of 29 Care Homes for Adults (18-65 years) updates as needed, including moving and handling, food hygiene and safeguarding. Staff must also received training on diabetes care and management. This must happen to ensure staff have sufficient knowledge to meet residents needs safely. 4 42 13 In line with Regulation 13(4) 31/03/2009 The registered person must be able to demonstrate through risk assessment that qualified first aid staff are on duty at all times as described in the CSCI policy guidance: First Aiders. This must happen to ensure residents health and welfare is not compromised. 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 28 of 29 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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 29 of 29 - 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. 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