Inspection on 16/03/09 for 7 Dove Lane

This inspection was carried out on 16th March 2009.

CSCI 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

7 Dove Lane 20/08/07

7 Dove Lane 07/02/06

7 Dove Lane 13/09/05

7 Dove Lane 02/03/05

7 Dove Lane 12/08/04

7 Dove Lane 20/02/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

Extracts from inspection reports are licensed from CQC, this page was updated on 18/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 7 Dove Lane 7 Dove Lane Harrold Bedfordshire MK43 7DF     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Andrea James     Date: 1 6 0 3 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: 7 Dove Lane 7 Dove Lane Harrold Bedfordshire MK43 7DF 01234720019 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Alan.Neate@aldwyck.co.uk Aldwyck Housing Association Name of registered manager (if applicable) Mr A Neate Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: 1. The registered person may provide the following category/ies of service only: Care home only Code PC 2. The maximum number of service users who can be accommodated is: 6 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 7 Dove Lane is a residential home for six adults with profound learning and physical disabilities. The detached bungalow was registered in 1993 and is located in the village of Harrold, Bedfordshire. The home is owned and managed by Aldwyck Housing Association. The home has six single bedrooms and these were a good size for ambulant people, however the changing needs of the people who use the service has Care Homes for Adults (18-65 years) Page 4 of 29 care home 6 Over 65 0 0 6 6 Brief description of the care home meant that the room sizes are not wholly adequate with the use of wheelchairs. The home has a lounge, dining room, kitchen, and laundry as well as bathroom and shower room, both including toilet facilities. Staff are provided with an office/sleeping-in-room, which has an en-suite facility. The home has its own vehicle with wheelchair access. The village has shops, pub, and church, which were all used by people who use the service. They also use the facilities in the nearby towns of Bedford, Northampton and Milton Keynes, such as theatres and cinemas. The weekly charges are £1176. This figure does not include various items such as some social activities, vehicle diesel costs, hairdresser or toiletries. 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: 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: This was an unannounced inspection undertaken on the 16th of March 2009. The manager was available for the inspection process which lasted for approximately 7 hours. The inspection process followed a case tracking methodology where a sample of people were randomly selected. These peoples files were inspected, their relatives spoken to and where possible their key workers interviewed. We were also able to view various records to be able to triangulate the information required to compile this report. The report also consists of information received from staff and relatives not case tracked and the Annual Quality Assurance Assessment (AQAA) received from the Care Homes for Adults (18-65 years) Page 6 of 29 service. What the care home does well: What has improved since the last inspection? Since the last inspection their was evidence to suggest the service met the requirements and recommendations from the last inspection. We were also informed that they had submitted plans to the County Council to be able to expand the facilities of the home which would make it better suited to meeting peoples needs. This had proved problematic and as a result had delayed the plans. The service have identified and have put in place measures to remove the people from the home to another of their sister homes which was better suited, while this works is being undertaken. We were informed that several areas of staff development had been identified and implemented to ensure the staff team are knowledgeable about the care they are required to provide. The manager sits on the Skills For Care board and is actively involved in the development of this for the organisation. We were told in the AQAA documentation that the service have built up a pool of 15 relief staff that ensures people are able to receive consistent service delivery. We were told that in an attempt the get young people into care they have organised coffee mornings where potential carers have been invited into the service. One person who have worked in the home as a part time employee while furthering her education spoke about the benefits this had on her. Feedback was that she was a very good carer who had embarked on her NVQ in care and had the potential to be a great asset to the care industry. Care Homes for Adults (18-65 years) Page 8 of 29 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 9 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 10 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided with sufficient information to people to be able to make an informed choice about using the service but further development was needed to ensure comprehensive assessments are in place for people who use the service. Evidence: The service had a Statement of Purpose and a Service Users Guide available. Both documents were inspected and in general provided sufficient information for potential users of the service and people who currently use the service. However the documents needed to be reviewed. The Statement of Purpose had some information that was current for example the staff qualifications were updated in February 2009 but this was not reflective of the other information held. The Service User Guide detailed the aims and objectives of the home but needed to be more user friendly to meet the needs of the people who use the service. We discussed Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: having the information in a more pictorial and symbolic format. The service had identified peoples needs through several methods but failed to demonstrate a comprehensive needs assessment that currently reflects peoples needs. We were told that these had been archived due to the length of time people were in the home. Since the inspection we received information that the assessments could not be located for some people. The importance of the document was explained to the manager. We told him that the needs of people would change and a holistic view of people must be evidenced. For one person it was evident that his needs had changed significantly since he moved into the home. We were told that the assessments undertaken were those from external professionals. All people case tracked had contractual agreements to include license agreements. These were signed and dated to reflect their placement and where fees had increased this was reflected in the documents inspected. Care Homes for Adults (18-65 years) Page 12 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Satisfactory procedures for ensuring peoples personal and medical needs were being met but further development was needed to ensure effective manual handling assessments are in place for people, as a result people could be put at risk. Evidence: The personal needs and choices of people who use the service was recorded in support plans. We inspected three of these plans in detail. In general some plans reflected a Person Centered approach to care while others needed to be developed to reflect the same approach. One care plan inspected showed information for next of kin, finance arrangements, life skills assessments, key workers meetings, personal care goals, medication, eating, drinking, bowel function, sensory, physiological, day activities faith etc. There was also evidence that the person was consulted about their care . We also saw a quick reference guide to be used for agency staff or relief. This was also accompanied by risk assessments for lack of control and choices, mental Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: capacity, incidents of abuse, scalding, back injury, falling out of bed and epilepsy. There was evidence that care reviews were undertaken annually we saw reviews undertaken in February 2008. The other two care plans inspected showed that similar information was available but these were not presented in the Person Centered approach that was evident in care plan one. The home ensured a health action plan was implemented for all people who use the service which covered medication and their side effects, personal information such as personal care, weight, doctors details and arrangements for people in the event if there death. The home needed to ensure a manual handling assessment was in place for all people who needed staff support when transferring. This was not evident in any of the care plans inspected. We were sent a manual handling assessment that was immediately implemented for one person soon after the inspection. There was evidence to suggest that despite peoples lack of ability to verbally communicate other forms of communication was implemented. These included pictures and symbols for people to be able to choose activities or favorite meals. We were informed that people were encouraged to take part in community activities such as horse riding and swimming on a regular basis. Care Homes for Adults (18-65 years) Page 14 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were given opportunities to take part in activities and as a result their social and personal lives were being enriched. Evidence: All people using the service had a care plan document on file with detailed information for staff to follow about their required needs. People had opportunities for personal development recorded on the care plans. We were told that the staffing levels had been increased in the past to facilitate people needing to access community activities but due to to budgetary restraints this was not sustainable. People have a structured activity plan that shows 3 internal planned activities and 3 external planned activities per week as a minimum. These included horse riding, snoezelan, corner club, music, karaoke, aromatherapy and the PAT dog. People were also encouraged to celebrate special events such as birthdays. Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: People were encouraged to be a part of the local community by having access to the local pubs and GP surgeries. We saw pictures of past events where people attended fun fairs in the community along with events that family members who visits the home on a regular basis were encouraged to part take in. People were offered a healthy diet and appeared to enjoy their meal times. We saw menus to suggest all meals were planned and choices were offered. Some people had soft diets and these were done to meet individual needs. We observed staff feeding one person which was carried out timely and respectfully with a good dialogue between them at all times. People were offered or fed various beverages throughout the day. We saw pictures of meals to suggest people were able to make choices about the meals they ate. C.Their was also flexibility offered to people as to the time that they would consume their meals. On the day of the inspection people were looking forward to a meal of chicken curry with pasta, naan bread followed by fruit with jelly and ice cream. Care Homes for Adults (18-65 years) Page 16 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. Peoples health care needs are assured in all aspects and their needs are handled with dignity and respect, however further development was needed to ensure medication received in the home are always checked and signed for. Evidence: The personal and health support given to people who use the service was of a high standard and this was evident in peoples records such as care plans and Health Action plans. Staff spoken to said we aim to provide the very best of care to the residents. There was evidence that the home had a good relationship with medical professionals such as doctors and physiologists. On the day of the inspection one person was taken to the doctors surgery while another was taken to the hospital for routine appointments. The staff members appeared competent and were able to quickly identify if people had any medical needs, even though they could not verbally communicate this. The manager said two people have been assessed under the Mental Capacity Act to ensure they can receive treatment that is available for them. All people who use the service were assessed for osteoporosis due to the likelihood of Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: them developing the disease due to prolonged usage of their current medication and their age groups. The manager said he was very keen to ensure people receive the best care. One person had broken his foot by a simple bang on the door frame and this was due to the onset of the disease. Other people were being treated for gall stones, kidney stones, bowel conditions, eating problems etc, which were being addressed in a positive way and proactive way. Staff spoken to were able to confirm that peoples health care was of paramount importance to them as a team. The home had policies and procedures in place for the safe receipt, disposal, recording and administration of medication. There were also procedures in place for administering controlled drugs, although at the time of the inspection no one was taking any controlled drug medication. We were concerned however that for one person his medication was received in the home but it was not recorded, neither were the medication checked upon receipt into the home. The prescribers instructions stated 20 tablets but was overwritten by a pen to say 28. We were informed that this was done by the pharmacist but their was no evidence to substantiate this information. Since the inspection we were told that the home had taken this up with the pharmacist. The storage and stock of medications inspected appeared satisfactory and the Medication Administration Records (MARS) inspected suggested people were being administered medication safely. On the MARS sheets two members of staff signed for medications administered at all times with the exception of some creams. The wishes and needs for people upon their death was recorded in Peoples Health Action plans. The home had also signed up to dignity and care programme to ensure staff are aware of how to treat people in all aspects of their lives. Care Homes for Adults (18-65 years) Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place for safeguarding people and listening to their complaints were satisfactory as a result people had good outcomes in this area. Evidence: The home have complaints procedure in place that ensured people are listened to and their best interest are maintained. A copy of the procedure was placed in communal areas of the home but some work could be done to these to make them more user friendly to meet the needs of people. Since the last inspection 1 safeguarding alert was made which was known to us. There were satisfactory investigative work undertaken to suggest the person was safeguarded. Staff spoken to said they were aware of the complaints procedure and knew how to report safeguarding issues. Training records suggested staff have had recent safeguarding training. Care Homes for Adults (18-65 years) Page 19 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People lived in a homely and comfortable environment but further development was needed to ensure the home is decorated throughout with modern furnishings. Evidence: The home was welcoming and provided a clean and comfortable environment for people to live. The service provided bedrooms for people that were decorated to meet individual tastes, all bedrooms seen provided people with equipments to meet their needs such as hi/low beds, hoists, wheelchairs etc. The space available for maneuvering was very limited for some people because the space available was not fit for purpose. In one bedroom the wall paper had peeled and was in need of redecorating. The home had two communal bathrooms and toilet facilities and as a result the service proved to be unfit for purpose. The service had identified this and plans were in place to re- house the people who live in the home by September 2009. The plans are to rebuild the home to make it fit for purpose in regards to size of bedrooms and ensuring en -suite facilities are available for people. The safety aspects such as water temperatures were maintained. We saw evidence to Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: suggest that risk assessments to protect people from burns were implemented. The shared spaces within the home complimented the needs of people although some furnitures were old at tattered in places. Some furnitures and doors needed re varnishing. There was also a need that areas of the home are decorated but with the fact that the plans are ahead to move people out of the home in the near future it was understandable that at this stage it would not make financial sense. The service employed an ancillary staff who ensured the home was cleaned on a daily basis. There was evidence that the service was furnished with appropriate industrial washing machines that had sluicing programmes along with driers to meet the needs of the people who use the service. Care Homes for Adults (18-65 years) Page 21 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service were protected by the skills and competency of the staff team but further development was needed to ensure a thorough recruitment procedure is implemented which protect people at all times. Evidence: We looked at 4 staff files which were randomly selected. The staff files detailed information about individual staffs personal development, job descriptions, probationary reports, supervisions notes, references, Criminal Record Bureau Check reference numbers, photo of the staff member,full employment history and learning and development plans which identified staff training needs. This information was available for all but one person where only one reference was seen to be obtained. We were told that the organisation was finding it difficult to obtain this reference. The home employed a mixture of full time, part time and bank staff. On the day of the inspection we were told that the home employed 15 full time equivalent staff but had 59 hours vacancy to be filled. The service ensured that 4 staff members are on shift at all times and the manager said he worked as a part of the rota. The staff spoken to appeared competent and knowledgeable about the care they Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: provide. One staff spoken to said I love it, we have a very good team. Another staff said we feel that we are listened to, and the people we care for are always top priority. When asked about the training they received one staff said, I have been on a lot of training. Other staff members spoken to were able to confirm that they received a lot of training. One staff explained that she received a lot of train bing in a very short time, these include Equality and Diversity, General Health, Rectal Diazepam, Mental Capacity Awareness etc. Another staff said, I feel confident here and I have opportunities for personal development. We saw evidence to suggest training needs were also identified for the future these included Deprivation Of Liberty, NVQ level 3,Learning Disabilities, Medication, Person Centred Training and Skills for Care. 6 of the 15 staff had already achieved their NVQ level 2 in care and a further 5 staff members had embarked on the training and was due to complete in the near future. Staff members spoken to said they received regular supervisions and we were able to confirm this by speaking to the manager and viewing supervision records kept on file. The staff team also had regular meetings the latest being on the 9th of February 2009. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in the best interest of people who use the service but some improvement are needed to ensure structures are in place that will provide support to the manager so he will not have to work as part of the rota. Evidence: Their was evidence to suggest people who use the service benefits from a home that was well run. The leadership of the home was evident in the way the manager liaised with the people who use the service and the staff team. We identified that their was a calm and relaxed atmosphere and people appeared happy. The manager clearly identified and worked in a proactive way to meet the needs of people who uses the service. The manager works actively on the rota as a part of the team and although this is commendable we were concerned that this detracts from being able to manage the home. When asked the manager said, I grab hours in the day. Some staff commented that they would like more staff but as discussed with the manager Care Homes for Adults (18-65 years) Page 24 of 29 Evidence: budgetary restraints have been implemented. Relatives spoken to said , we are very happy with the care. One relative said, I have no concerns and if I did I would know how to complain. Staff spoken to said , the manager is very friendly and you feel that you are listened to. Another staff said , I like the management team they are very approachable, they have good communication with the residents. The service have identified the need to monitor the views of people who use the service and as a result have sent out questionnaires to relatives who act as peoples next of kins. These questionnaires have been collated but further development was needed to ensure the information is analysed and published.We discussed with th manager other aspects of quality assurance that could be implemented to provide evidence that peoples views are listened to. The service had a health and safety procedure and policies were in place to ensure peoples safety could be assured. We saw several records such as a water temperature checks, fire records, Infection Control procedures for washing hands and training DVDs on how to maintain health and safety in the work place with evidence that staffs knowledge was tested. 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 2 14 Arrangements must be 30/04/2009 made to ensure a comprehensive assessment is in place for all people who use the service. This will demonstrate your ability to identify and meet the needs of people who use the service. 2 9 13 Arrangements must be made to ensure manual handling assessments are implement for people who needs to be transferred by staff. To safeguard people who use the service and the staff team from harm. 30/04/2009 3 20 13 All medications received in the home must be accounted for. To prevent medication error that may put people at risk. 30/04/2009 Care Homes for Adults (18-65 years) Page 27 of 29 4 34 19 Arrangements must be made to ensure effective recruitment procedures are implemented and carried through at all times. To protect people from potential harm. 30/04/2009 5 37 9 All efforts must be made to ensure the manager is able to work supernumerary to the rota. To be able to maintain a well run home in the interest of people who use the service. 30/04/2009 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 1 The Statement of Purpose and Service User Guide should be reviewed and presented in a format that meets the needs of people who use the service. Arrangements should be made to ensure the quality assurance system is developed and the information is analysed and published. 2 39 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. 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