Inspection on 28/10/08 for 87 Bouncers Lane

This inspection was carried out on 28th October 2008.

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

87 Bouncers Lane 16/11/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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: 87 Bouncers Lane 87 Bouncer`s Lane Prestbury Cheltenham Gloucestershire GL52 5JB two star good service The quality rating for this care home is: 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: Lynne Bennett Date: 2 8 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) 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. Internet address www.csci.org.uk Information about the care home Name of care home: Address: 87 Bouncers Lane 87 Bouncer`s Lane Prestbury Cheltenham Gloucestershire GL52 5JB 01242572446 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) : earthyandproud@hotmail.com CareTech Community Services Ltd care home 4 Number of places (if applicable): Under 65 Over 65 4 0 learning disability Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) The maximum number of service users who can be accommodated is 4. Date of last inspection A bit about the care home 87 Bouncers Lane is a semi-detached property situated in a residential area of Cheltenham. The home is currently registered to provide accommodation for up to four adults who have autistic spectrum conditions. People are accommodated in single rooms. There is a bathroom and shower room. The home also has a lounge and a kitchen/dining area. The office has been relocated to a room on the first floor. Prospective people and others involved in their care are provided with copies of the Statement of Purpose and Service Users Guide. Additional copies of these can be obtained from the office. Fee levels were reported to be between 1051 pounds and 1400 pounds per week. 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 How we did our inspection: This is what the inspector did when they were at the care home This inspection took place in October 2008 and included a visit to the home on 28th October by one inspector. We spent time talking to and observing people living in the home, talking to staff and the manager. The manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). A selection of records were examined including care plans, risk assessments, medication and financial records, staff files, quality assurance audits and health and safety systems. A walk around the environment was completed. The current level of fees for the home are between 1,000 pounds and 1,466 pounds per week. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the care home does well People are enabled to communicate their choices using a variety of approaches, verbal communication, use of objects of references and photographs. These are acted upon both on a day-to-day and longer-term basis, helping service users to feel in control of their lives. Staff are patient and sensitive to the needs of people they support. People living in the home are enabled to access activities appropriate to their needs and interests, and to stay in contact with family and friends. They were observed going to a day centre and out for a walk. One person said they had been to a friends house the evening before. Both were observed choosing where to spend their time and with whom. Staff had a good understanding of the needs of the people they support. A varied and balanced diet is provided for the people living in the home, with account taken of their preferences, choices and dietary needs. What has got better from the last inspection Eleven requirements were issued at the last inspection and these have all been complied with. Care plans and risk assessments were up to date with evidence of regular review. Shortfalls in the storage of medication were being addressed. The kitchen floor had been refitted and there were plans in place for further refurbishment of the kitchen. Training had been arranged for staff, including access to autistic spectrum disorder courses and information. A training matrix was in place providing evidence of refresher training, training completed and training which had been booked. The manager was appointed after the last inspection and had applied to become registered with us. What the care home could do better A full assessment of need must be completed and/or obtained for people wishing to move into the home so that a decision can be made about whether their needs and aspirations can be met. Planned refurbishments to the kitchen and laundry must be carried out. Some improvements to the administration of medication need to be made. Confidential information must be stored securely. Greater consistency is needed in the monitoring of some health and safety systems. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Lynne Bennett CSCI Colston 33 Bristol BS1 4UA 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 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 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 . People have access to a range of information enabling them to make a decision about whether they wish to move into the home. Obtaining and collating an assessment for people wishing to move into the home will ensure that their needs and aspirations can be met. Evidence: The home has a Statement of Purpose and Service User Guide which have been produced a version appropriate to the needs of people who may live in the home. It made good use of large text, pictures and photographs. Both documents had been reviewed in September 2008. Each person had copies on their personal files and the manager confirmed that new people were given copies prior to visits to the home. One person had moved into the home since the last inspection. They had previously lived in another local home owned by CareTech. The manager stated she had not obtained an assessment or care plan from the placing authority prior to admission and realised this these documents should have been obtained. An assessment by CareTech had also not been completed. The manager had attended meetings prior to admission with the placing authority and family to plan the admission and reflect on visits to the home. A report confirmed that the person had successfully had a tea visit and planned an overnight stay. The manager stated future admissions would be assessed by her and she would ensure all documentation was obtained prior to people moving in. Since the last inspection two people had moved onto alternative accommodation. One person had expressed the wish to live more independently and they had been supported by the home to achieve this. The other person by their behaviour had indicated they were not happy and they were supported to find alternative Evidence: accommodation where the manager said they have settled in well. The manager said that CareTech were considering changing the numbers of people living at the home to 3. They will need to apply for a variation to their registration, if they should decide to do this. Each person had a statement of terms and conditions in place which provided information about the fees payable by them. The service user guide provided additional information about any additional payments they might need to make such as for holidays and chiropody. 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 . A person centred approach to care planning provides the opportunity for people to take control of their lives. Peoples needs are being assessed and they are being supported to makes decisions about their lifestyles. Risks are being managed safeguarding them from possible harm. Evidence: The care of two people living in the home was case tracked which involved reading their care plans and other related documents, observing the care provided and talking to staff about the support they gave. One person had a Person Centred Plan in place which provided a holistic assessment of their needs. The manager confirmed that this assessment would be developed for the other person. Both people had a range of care plans in place identifying their social, physical, emotional and intellectual needs. There was evidence of regular review. Reviews were taking place with placing authorities and families. An assessment of need and care plan had been supplied for the person who recently moved into the home. One person had signed their plans. A read and sign list was provided for staff which indicated that they had read care plans and risk assessments. Staff were observed following guidelines in care plans and risk assessments. For instance one person does not like to wear clothes and their records indicated that they must wear clothes in communal areas. Staff were observed sensitively and discreetly prompting the person of this thereby promoting their personal preferences and their Evidence: dignity. Communication plans provided staff with information about the way in which people liked to communicate and how to interpret their non verbal behaviour. For example, staff were observed patiently and calmly repeating short statements to one person 2 or 3 times allowing them to process the information. There were very few restrictions in the home. The front door was kept locked and staff described the rationale for this. Care plans were in place for one person indicating why this had been done. The manager will need to review this documentation with the placing authority in consideration of the implications of the Deprivation of Liberty Act to be implemented in 2009. A listening device was being used for one person to monitor their epilepsy. Staff were observed switching this off during the day and said that it was only used during the night. There was no guidance in place for this or any agreement to its use. A visit had been arranged to the home from Changing our Lives Advocacy Service and a report had been produced by the advocate which made positive comments about the service provided to people living in the home. The manager said they were trying to find an advocate to visit people on a regular basis. Some information in care plans and risk assessments referred to Gloucestershire Autism Services, the former service providers. The manager said that these would be amended to make reference to CareTech. During the visit to the home some personal information was left in the kitchen such as daily records and the communication book. Secure arrangements must be made for these documents if they need to be accessible in the kitchen. A comprehensive range of risk assessments were in place for each person indicating hazards and how these were to be minimized. For one person with epilepsy the appropriate risk assessments were in place. This person also goes swimming and further information should be added to this risk assessment to indicate what was in place to ensure their safety should they have a seizure whilst in the pool. The manager said that two members of staff were usually in the pool and another member of staff in the nearby vicinity. The home had a missing persons policy and procedure in place. Both people need one to one support when in the community. It is recommended that the manager develops a pen picture/description with accompanying photograph should a person become separated from staff. 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 live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. Evidence: Each person had an activity schedule in place describing a range of community, social, recreational and educational activities which they have the opportunity to attend. One person had a large notice board in the kitchen which they had decorated displaying their activities for the week. Peoples dairies were sampled for two weeks in September and October confirming that they were being offered these activities. Occasionally one person refused to participate and this was recorded, with alternative activities offered within the home. In total contrast the other person liked to be out and about and preferred to be kept busy. Their diary confirmed they had lots of opportunities to go to day centres, college, social clubs, meeting friends and family and trips out. One person liked to go swimming on a regular basis and for walks. Staff had obviously researched parks and areas to go to with a great variety of venues being offered. The other person loved visiting old buildings and were often taken to churches or historical buildings. A sensory room had been developed on the ground floor which people used during the visit. Music, television, books and DVDs were also provided and seen to be well used. Evidence: In the garden a trampoline had been provided and staff were looking at providing other equipment such as a climbing frame. The daily notes included a selection of photographs of recent activities people had taken part in. Staff said these were then put into larger albums which one person particularly enjoyed looking at. They said these photographs were also used to reinforce activities with people. This is excellent practice. Close contact was being maintained with families and friends. People visited their family regularly or had visits to the home. One person liked to keep in touch using the telephone. Friends were being encouraged to visit or people were supported to go to their friends. Individual talk time sessions were being held with people to chat about their lifestyles and the home with records being kept for meetings in March, May and July. Staff were observed spending time with people in communal areas or providing space when people chose to spend time in their rooms. Staff said that one person would occasionally help around the home with cleaning or making sandwiches or drinks. A menu was displayed in the kitchen/diner for the weeks main meals. One person asked for chicken for lunch and this was provided. Fresh ingredients were being used to produce main meals. Fresh vegetables and fruit were in evidence in the kitchen. One person had a gluten and cassein free diet. Staff had a good understanding of their needs. There was evidence that further advice had been sought from healthcare professionals in relation to this allergy and that diet information was in place. There were several places where people could choose to eat their meals. One person liked to eat in the garden and staff were thinking about alternative arrangements which could be made during the colder months. Dining facilities were provided in two rooms in the home. 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 care support is offered in a way that responds to peoples needs and preferences, promoting peoples dignity. There are some improvements in the administration of medication that need to be implemented to safeguard people from the risk of error or possible harm. Evidence: The way in which people wish to be supported was clearly highlighted in their care plans. Both had identified the gender of staff providing their personal care and records confirmed this was respected. Clear guidance was provided for staff about how personal care should be delivered. Staff spoken with had a good understanding of this. During the visit a healthcare professional visited to assess one person living at the home and another healthcare professional was due to visit the following week. It was evident from records that the home were working closely with the local Community Learning Disability Team. Each person had a Health Action Plan in place which included information about regular appointments with a range of healthcare professionals such as their Doctor, Dentist, Optician and Chiropodist. Outcomes of appointments were recorded. Systems for the administration of medication were inspected and found to be mostly satisfactory. Staff had completed training in the handling of medication and were booked for refresher training in January 2009. A letter from a healthcare professional confirmed they had also completed training in the administration of Midazolam. The manager said she would be completing audits of staff competency. Protocols were in Evidence: place for as necessary medication and staff were following these. Medication for one person was being administered covertly and a best interests multi disciplinary meeting had been held in April 2007 to assess whether this was appropriate. This document will need to be reviewed. Medication administration records had been completed with only one error where a handwritten entry had not been countersigned, others had been completed correctly. Stock records were kept for all medication and a returns book was being used. Homely remedies were being used occasionally but there were no records in place to indicate that a Pharmacist or Doctor had approved their use. The copy of the British National Formula being used was out of date. 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 . Systems are in place that enable complaints and concerns to be raised by people using the service or on their behalf. People are safeguarded from possible harm or abuse. Evidence: The home had a complaints policy and procedure in place which had been produced in a format using large text, pictures and symbol. Copies of this were available in the home as a stand alone version or included in the Statement of Purpose. One version of this procedure did not provide our contact details. The DataSet indicated that 4 complaints had been received in the last twelve months. Another complaint had been received just before the inspection. The complaints log provided detailed information about the complaints and the action taken as a result. Copies of letters sent to complainants were on file. It was evident that environmental changes had been made as a result of complaints and that guidance was in place for staff to minimise noise within the home. Staff had attended training in the safeguarding of adults and understood their responsibility and identifying abuse to their registered manager. Those spoken with said they had confidence that she would challenge poor practice and take the appropriate action. Copies of the local safeguarding procedures and No Secrets were available for staff. The AQAA stated staff have a good understanding of safeguarding procedures as well as the whistle blowing policy and procedure. This was also confirmed in a recent quality assurance audit of the home by an external auditor. Staff said they had attended training in the management of challenging behaviour which had provided them with the knowledge and skills to use diversion and distraction effectively with people who may become distressed or anxious. They were observed using this effectively with one person during the visit to the home. The AQAA stated, Due to our excellent Management of Challenging Behaviour training, staff are skilled at delivering a low arousal approach of support at times of high anxiety. Staff talked through the forms they completed after an incident and said that physical intervention was rarely used. On one occasion a member of night staff had used a physical Evidence: intervention with one person recording this in the diary and on an incident form. A separate physical intervention form had not been completed. The registered manager said that this would be addressed and she would review access to the forms putting copies of the physical intervention form with incident records. Care plans indicated that people needed support with their finances. Robust financial records were in place, with receipts being cross referenced with credits and debits. Regular checks were in place. 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 kitchen and laundry need refurbishment to ensure that these areas are clean and hygienic. Other communal areas provide a safe and comfortable environment, which reflects peoples lifestyles and interests. Evidence: The home was located in a busy road in near to the village of Prestbury with parking to the front for several vehicles. The house was semi-detached with pleasant gardens to the rear of the property. The communal areas were pleasantly decorated with good fixtures and fittings providing several areas for people to spend time on their own or in company. A sensory environment had been created in one room which also had comfy chairs and dining furniture. The lounge offered people a comfortable area to listen to music or watch the television. The floor in the kitchen/diner had been refurbished and the manager confirmed there were plans to replace the fittings in the kitchen later this year. The managers office had been relocated to an upstairs room which had formerly been used as a fourth bedroom. The laundry was in desperate need of attention and the manager said that a surveyor had visited the home to make plans to create a separate laundry with hand washing facilities and a small office. The ceiling in the laundry was collapsing in one part. The medication cabinet was located here but a new cabinet had been ordered and was being fitted in the new office. The home was clean and tidy at the time of the visit and there were no odours in private or communal areas. Staff had completed infection control training and appropriate measures in the kitchen and laundry were observed to be in place. Hazardous products were kept securely. 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 . Peoples needs are met by a competent staff team, who have access to a comprehensive training programme that provides staff with the opportunity to gain knowledge about the diverse needs of people living at the home. Evidence: The AQAA stated,The majority of staff at Bouncers Lane have been with us for over 5 years. The staff team are generally a positive, creative and intelligent group of people who are passionate about the work they do and the people they support. Service users have been able to build up solid and trusting relationships with staff with whom they have had contact consistently for years. Interactions with staff during the visit confirmed this, they appeared to have a good understanding of peoples needs which they were able to express to us and put into practice. The DataSet indicated that 8 of the staff team of 11 had a NVQ qualification. New staff confirmed they completed a corporate induction programme and one person was working on their Learning Disability Qualification during the visit. Copies of induction booklets were kept on individual staff files. An agreement had been put in place with CareTech to keep recruitment and selection records at Head Office, therefore it was not possible to verify whether records complied with our regulations. Files for new staff contained a front sheet which contained information about when records were obtained including references and a Criminal Records Bureau check. Some of these sheets indicated whether a full employment history and reason for leaving former employment had been obtained. Staff confirmed that they had regular access to training and several said the training programme was great. A training matrix indicated that refresher training had been booked for staff in food hygiene and administration of medication. They had attended Evidence: training in the safeguarding of adults and some had completed Mental Capacity Act training. Specialist training in learning difficulties, epilepsy and autism had also been provided. The manager said that supervision sessions were now taking place and staff confirmed this. Copies of supervision sessions were in place on staff files sampled indicating that staff had received up to three supervision sessions in the past six months. Staff meetings were also taking place and staff said that communication systems within the home were really good. 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 . People benefit from a well run home. Effective quality assurance systems are in place involving people who live there. Satisfactory health and safety systems are in place which if completed consistently will provide a safe environment. Evidence: The manager had considerable experience in the field of learning disability and had worked in the home for 8 years. She confirmed she was completing the Registered Managers Award and NVQ Level 4 in Health and Social Care. Staff said she was open and approachable. She appeared to have positive relationships with the people living in the home. She had applied to us to become the registered manager. CareTech had completed Regulation 26 visits to the home. This was now being carried out by the Area Manager but had previously been done by a manager from another service. A copy of the most recent report was available for inspection. The manager stated the other reports had been taken away for typing and would be returned to the home. A quality assurance audit had been completed in September this year by an auditor from CareTech. A report with action plan had been produced. People living in the home had been involved in this process and staff had been asked to complete feedback forms. Health and safety systems were in place and monitoring records were inspected. Systems for checking fire equipment were being completed regularly and staff had access to fire training and had been involved in one fire drill this year. A fire risk assessment was in place. Additional general risk assessments had been carried out both for the environment and for people living in the home. Other checks for fridges and freezers and testing of water temperatures had been carried out regularly but Evidence: there were recent gaps during October. There were several records being used and the manager said these would be reviewed so that staff were clear when they should be completed. Food in fridges was labelled correctly and the temperature taken for hot food. The AQAA confirmed regular servicing and testing of other utilities and equipment in the home. Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 2 14 New people must not be 10/12/2008 provided with accommodation until an assessment of need has been obtained and/or completed. This is to make sure that the home is able to meet their needs and aspirations. 2 9 13 The risk assessment providing guidance about how a person is supported when swimming must indicate how they would be supported if they had an epileptic seizure. 10/12/2008 This is to safeguard the person from possible harm. 3 10 17 Records containing information about people must be kept securely at all times. 10/12/2008 The confidentiality of information must be respected. 4 30 23 The laundry needs to be refurbished and the kitchen fittings replaced. 10/03/2009 This is to promote good infection control and provide an environment which is safe and clean. 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 2 3 4 5 6 2 6 7 20 20 23 A record should be kept of visits to the home to start to build up a picture of the persons needs. A person centred plan/assessment should be put in place for the person who recently moved into the home. Guidance for the use of a listening device and consent for the use of this should be drawn up. Best interests documents for the covert administration of medication should be reviewed annually. An up to date copy of the British National Formula should be obtained. Physical intervention forms should be completed to complement incident forms when this kind of intervention is used. Appropriate hand washing facilities should be provided when the laundry is refurbished. Fire drills should be conducted with more often in line with the fire risk assessment. Monitoring records for fridges, freezers and hot water should be completed regularly. 7 8 9 30 42 42 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 © (2008) 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. 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