Inspection on 19/01/10 for Andelain

This inspection was carried out on 19th January 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Andelain 03/03/09

Andelain 10/03/08

Andelain 11/01/07

Andelain 01/02/06

Andelain 02/11/05

Andelain 10/03/05

Andelain 31/08/04

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 28/03/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: Andelain 12 Eugene Road Preston Paignton Devon TQ3 2PQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Stella Lindsay     Date: 2 1 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Andelain 12 Eugene Road Preston Paignton Devon TQ3 2PQ 01803559336 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Miss Carole Louisa Byrne care home 7 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Registered for a maximum of 5 LD(E) Registered for a maximum of 7 LD Date of last inspection Brief description of the care home Andelain is a home for up to seven adults who have a learning disability; some of these people may be retired. The home has three floors, with the owners occupying the top floor. The home is near to shops and the sea front. There is a garden, down a few steps from the house. The current range of fees are from 475 to 520 pounds per week. A copy of the last inspection report is kept in the dining room. 0 3 0 3 2 0 0 9 7 Over 65 7 Care Homes for Adults (18-65 years) Page 4 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 visited Andelain on two days in January. We met all the people who live there, the home owner Carol Byrne and her partner, and the staff who were working there. We looked at care plans and other paperwork. We saw how well medicines are organised, to help people keep well. We saw how people are helped to look after their own money. We looked round the house. We did all this to see what it is like for people to live at Andelain, and to see how safe Care Homes for Adults (18-65 years) Page 5 of 29 they are kept. Care Homes for Adults (18-65 years) Page 6 of 29 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 Care Homes for Adults (18-65 years) Page 7 of 29 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 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. Thorough assessment was carried out before care was offered, and admission was arranged carefully in consideration of peoples emotional needs. Evidence: Andelain has a statement of purpose and service user guide which contain pictures and symbols to help people understand the text. The service user guide contains information about the home and the services offered which helps people to make a decision about whether the home is the right place for them. The home owner told us she has plans to consider how to make it more understandable for people who might use the service. There had been one admission since the previous inspection. The home owner had met with the person and their family, and completed a check list to ensure they considered all aspects of the care that would be needed. A social work assessment was provided, and information was also shared by staff from the day service attended. The person came to Andelain for initial visits, then came for a two week trial that was extended and accepted as a long term placement. A basic care plan was drawn up Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: before the admission, to provide staff with information they would need. The family also provided a My Life book, with family photos, for the persons comfort and to enhance understanding of those who lived and worked at the home. The prospective service user and their family had known the people who live and work at Andelain over several years, having shared social occasions. A relative told us that at the time of the move, Andelain had been like a home from home, and that the support given to the whole family over this period was excellent. This good work was underpinned by understanding that had been built up over many years, enhancing confidence for all. The home owner should also include in her admission practice, in accordance with regulation 14, that when the decision has been made following suitable assessment and consultation, she will confirm in writing to a prospective service user that the home is suitable for the purpose of meeting their needs in respect to their health and welfare. Care Homes for Adults (18-65 years) Page 11 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 could be confident that their changing needs would be met, as care plans and risk assessments were accurate and up to date. Further work was needed to consider decision-making and residents goals. Evidence: We saw that care plans were in place for each resident, including good details to advise staff of the personal care needed, and how much the person could do for themself. They were up to date, so staff were being given accurate information. There was not evidence that residents agreement had been obtained, but communication with families and health professionals was found to have been good. Each resident had an All about me book, which were completed to varying degrees. The Manager was in the process of gathering photos and information from family and friends of residents, and working with them to compile their Person Centred Plans. This work needed further development, to consider with residents what is important in their lives and how they can consider and work towards their goals. Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: Residents were given support to manage their money, according to their needs. One person had a filing cabinet in their room. The home owner kept records in the office to maintain security, but provided the residents with duplicates so they could keep their understanding and independence. Staff had not yet received training in the Mental Capacity Act to help them support their residents in decision-making. One resident was expecting to be assessed for medical treatments. The home owner told us that the MCA Support Worker at the hospital had been in touch and would support them in understanding any decision that became necessary. We saw risk assessments in place with respect to a physically frail resident, dealing with seizures, skin breakdown, eating, mouth care, the use of bed rails, and going out. These had been reviewed in November 2009, in response to changes in the persons strength and capabilities, which is good practice. We saw that risk assessments had been appropriately carried out for other people, for example in respect to the possibility of a seizure while traveling in a vehicle, or responding to fire alarms in the case of someone who had hearing difficulties, and safety in public places for another person. This is to prepare staff to deal with problems while enabling residents to live according to their wishes. Care Homes for Adults (18-65 years) Page 13 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 had a variety of activities, which suited their capabilities and interests. They joined in house and garden activities according to their own preference. Their meals were varied and nutritious. Evidence: Efforts were being made to involve residents in household tasks. One was keen to make their own packed lunch every day. Another went shopping with the home owner every Friday. One resident had said they want to do their own laundry. The home owner told us this had been attempted unsuccessfully, but would be working with a new member of staff. Two residents like to clear the table after meals, and to fold their clean clothes. A staff member told us they had done some food preparation and cookery with residents in the kitchen. Residents attended day opportunities that suited them. Some were collected by regular transport, some able to walk to work. The home owner told us that they meet Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: with staff from the Community Resource Centre to discuss residents needs and choices, to ensure that residents are suited to their day activities. Three residents were at home throughout this inspection, due to age or their state of health. One had retired, and made themselves comfortable in the lounge. We were told they enjoyed knitting and watching television. Another was being nursed in bed, and was provided with music and balloons for sensory stimulation. A projector had been provided for making light shows on the ceiling. The other resident was indoors throughout this inspection due to health problems, plus bad weather. They told us that they needed support to go out, and that one of the staff had taken them out in a wheelchair. Residents have been well supported to keep in touch with family and friends. One was being helped to keep in touch with their family by the use of a computer link, as well as regular visits from friends and family. A relative told us they were very satisfied with the quality of life provided by the home. Four residents had recently enjoyed a trip to the theatre, while two others changed their minds and stayed at home. Residents had enjoyed their holidays. In earlier years they had been on several foreign trips, and last year went to Butlins. Currently two residents were not well enough to go away for a holiday, and the home owner told us she was considering providing day trips instead. However, the five other residents should be consulted on their preference in this respect. Residents told us that sometimes they got to choose what they would have to eat. They were pleased with the prospect of pizza, that was being prepared for supper during this inspection. We were told that they would also be offered salad with it, and that healthy eating was encouraged. We saw that residents who were home during the day were asked what they would like at lunchtime, and it was provided. Care Homes for Adults (18-65 years) Page 15 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. Residents health and personal care were provided with diligence and with respect for their wishes, so that good health was maintained as far as possible. Evidence: The home owner and her partner, who were solely providing the care in the home on the first day of this inspection, were observed as providing sensitive personal support to residents. One resident was being nursed in bed at the time of this inspection. The home owner had consulted the GP, and District Nurses said their experience was that the home owner would call on them if there were any significant problem. There was evidence of consultation with the Speech and Language therapist, dietitian, and Occupational therapist, for advice and equipment. A physiotherapist had provided an exercise programme, which was carried out daily with support from staff. Clear information was provided for staff with relation to pressure areas and skin care. All residents were being supported to attend health care checks. There was a booklet with photos to help staff discuss health treatments with the residents. A clear plan of care had been provided by a District Nurse with respect to catheter care. Good support was being provided with diabetes care. The Manager was able to monitor and administer medication. The person had been provided with a drinks chiller, so they could have the Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: drink of their choice throughout the day or night. Seizure profiles were recorded for residents as necessary. Training updates in epilepsy care would be advisable. Currently, only the home owner was qualified to administer medication in an emergency. Information about epilepsy, and a code of practice was available for staff. We examined the system for administering medication, and found that it was accurate and well recorded. A Senior carer had completed a monthly audit, so that the home owner could be confident of the accuracy of these records. A chart had been started to record any change of prescription by the GP by phone, with two staff signing as witness, to ensure accuracy, as recommended by the inspection of this system by the supplying pharmacist in November 2009. Care Homes for Adults (18-65 years) Page 17 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 were confident that they could speak to the home owner or any staff and their views would be heard. However, policies and procedures were not in place to ensure that any allegation of abuse would be dealt with properly to remove risk of harm. Evidence: We observed that residents felt at ease with the home owner, her partner, and with the staff. We consider that good communication between all people in the house would enable people to make their concerns known. However, the homes policy on safeguarding people had not been revised since 2004, and did not include the locally agreed strategy on dealing with allegations of abuse. The Alerters Guidance could not be found. In-house training on recognising signs of abuse had been provided for the staff. It was recommended that training on safeguarding adults be obtained via the local authority, in order that staff and management are clear about what they would do if any allegation of abuse were made. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This pleasant house needs further work to make it safe and accessible for the residents. Evidence: Andelain provides a pleasant and homely environment for the residents, with excellent access to local facilities and transport links. There was an attractive garden at the back of the house. The home owners had plans to build a ramp, as not all the residents were able to go down the steps to the garden. Any maintenance issues come straight to the home owners partner for action. He told us that risk assessment had shown that a further radiator in the lounge needed to be covered, due to different furniture arrangements, putting a resident at potential risk, and that this would be actioned promptly. We saw that residents rooms had been personalised, with items of their own choosing, from filing cabinets to football regalia. Three residents were pleased to show us their room, and were very pleased with them. All were delighted with the new large screen televisions that had recently been provided. Two people were sharing a double room. Although not currently able to express their choice, they had been sharing for many years. We could see that they were still happy with this arrangement, which needs to be kept under review, due to one persons increasing health needs. There were not Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: locks on bedroom doors or toilet doors. Residents told us they were disturbed by other residents entering their room. Audio monitors were in place to alert staff when a person was having a seizure. One person told us they plugged in their own monitor at bedtime. The laundry had been relocated upstairs, and was in good order, with good surfaces to walls and floor, giving a hygienic area. The home owners had started refurbishing the upstairs bathroom during 2009. Residents were continuing to use it, as it contained the only toilet on the first floor. The floor was bare wooden boards, and therefore not suitable for being kept in a clean and hygienic state. 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 were well motivated and well able to communicate with people who live at Andelain. There were not enough staff to maintain the service if the home owner were to be unavoidably absent. The service had not provided sufficient training to enable staff to meet peoples needs in a safe and satisfactory way at all times. Evidence: There are always at least two staff available to care for the residents. Sometimes this is the home owner and her partner, but there are other staff available, who work regular shifts to enable the home owners to do other things, and sometimes to enable outings and other activities. At night there is always one awake staff member. Sometimes there is an additional staff member on sleeping in duty, but other times the home owners take this back-up role. We found that the staff appointed were working well with the residents, communicated well with them and with the home owners. Recruitment has sometimes been through word of mouth. A candidate phoned the home during this inspection. The home owner told us that she would send an application form, then invite the person to interview. If this were satisfactory, the candidate would be invited for an evening visit, in order to meet all the residents. We looked at the documents of recently appointed staff. We found that the procedure Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: being followed was good, with all checks being sent for. In one case a staff member had been working with residents before the arrival of two of the checks. The home owners had not been diligent in following up their requests for information, to ensure that residents were protected from potential harm. We consider that recruitment should continue, as the home owner had not fulfilled all management tasks required by the National Minimum Standards in order to assure a safe and responsive service, and needed more time released from caring duties. Also, she should be able to ensure that if she were unavoidably away from the home for any length of time, the residents lives would not be disrupted. Some staff training had been provided. An induction programme had been started with the newly recruited staff member, but had not completed the fire safety element, which is essential. In-house training had been provided for Health and Safety, Food and Nutrition, and Infection control. Training had been provided for Moving and handling. This had not covered use of the hoist, which had recently been introduced for one resident. Staff would benefit from further training in dementia care, epilepsy care and diabetes. They needed training in the Mental Capacity Act to help them uphold residents rights, and updates in their fire safety taring, to ensure that they would react correctly to protect residents in an emergency. The home owner had produced a suitable format for recording individual supervision sessions with her staff, but had not yet put it into practice. Care Homes for Adults (18-65 years) Page 22 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. The home owners run Andelain in the best interests of the residents, in terms of day to day care provision, though some health and safety issues were outstanding. Evidence: The registered provider and manager of Andelain is Carol Byrne. She holds the Advanced Care Management Certificate (City and Guilds) a qualification in Foundation Management, and a qualification in Community Care. She has had many years of experience of owning and managing a care home for people with a learning difficulty. Her ethos is to run Andelain as a real home and not an institution, which is well accepted by the people who live there and their relatives, as well as the staff. However, systems and staffing need to be boosted to enable the home owner to fulfill management tasks more satisfactorily, and the home should be set up in such a way as it would be able to continue functioning satisfactorily in the temporary absence of the home owner and/or her partner. The home owners have procured a system that will enable them to show how their home is performing against the National Minimum Standards. They had not yet started Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: making this audit. They had also produced a new set of questionnaires, ready to send to relatives and health and social care professionals, to gather feedback to help inform this review. The fire precaution system was compromised, as some residents like to prop open their doors during the day. One person told us they like to be able to call for help during the day. Another would need the door to be held open so that they would have time to manage the step outside. The home owner must research a style of door closer that will meet the needs of the residents, while sustaining their protection in an emergency. The fire alarm system had been checked professionally in October 2009. Drills had been held, but not fire safety training, and the homes fire safety risk assessment was in need of review. Care Homes for Adults (18-65 years) Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 34 19 (1) (b)(i) The registered owner must 11/04/2008 ensure that there is a robust recruitment programme operating within the home, which includes the receipt of two written references. This will ensure that only suitable people are recruited to provide care to the people who live at the home and therefore protect the people who live at the home. Care Homes for Adults (18-65 years) Page 25 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 23 13 The home must have an up 31/03/2010 to date policy and procedure on safeguarding vulnerable adults. This is to ensure that staff working at the home are clear about their role and responsibility for safeguarding residents well being and safety. 2 26 12 Suitable locks must be fitted 31/03/2010 to toilet doors and to residents private accommodation. This is to ensure the home is respecting the privacy and dignity of service users. 3 30 13 The refurbishment of the upstairs bathroom must be completed. This is to eliminate potential risks to the health and safety of the residents who are using it. 31/03/2010 Care Homes for Adults (18-65 years) Page 26 of 29 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 42 23 The home owner must 31/03/2010 provide professional fire training; up date the homes fire risk assessment, and consult with the fire safety officer with respect to suitable door closers. This is to assure the safety of people in the home in the event of an emergency. 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 The registered person should, following consultation and assessment, confirm in writing to a prospective service user that the home is suitable for the purpose of meeting their needs in respect to their health and welfare. The home owner should continue consultations with residents (and their families and/or representatives) in order to develop their Person Centred Plans. Although there were sufficient staff to meet the residents care needs, the staff team should be increased so that the home owner may be free to complete management tasks, and also in order that the team could be robust enough to cope with the temporary absence of the home owner. Systems should be in place to ensure staff training is recorded and updated regularly. Staff should receive training in the Mental Capacity Act, to enhance support for residents in making decisions, so that their rights are respected. Staff should receive training in epilepsy care, to ensure that residents may be suitably cared for at all times. It would be good practice to obtain training on 2 6 3 33 4 35 Care Homes for Adults (18-65 years) Page 27 of 29 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 safeguarding adults from abuse via the local authority to ensure that staff and management work in accordance with locally agreed protocols to protect service users from potential harm. 5 36 The home owner should meet regularly with staff for individual supervision sessions, to give them feed back on their performance, check their understanding of the homes policies, and to discuss any issues and training needs. The quality assurance programme should be carried through, to show where shortfalls might occur, and enable the home owners to produce an improvement plan in response, in consultation with service users and other interested parties. 6 39 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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