Inspection on 14/04/09 for Anita Jane`s Lodge

This inspection was carried out on 14th April 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Anita Jane`s Lodge 29/03/10

Anita Jane`s Lodge 24/11/08

Anita Jane`s Lodge 29/04/08

Anita Jane`s Lodge 14/11/07

Anita Jane`s Lodge 09/07/07

Anita Jane`s Lodge 15/06/06

Anita Jane`s Lodge 22/09/05

Anita Jane`s Lodge 12/04/05

Anita Jane`s Lodge 07/10/04

Anita Jane`s Lodge 05/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 20/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Anita Jane`s Lodge 126/128 Uppingham Road Leicester Leicestershire LE5 0QF     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ruth Wood     Date: 1 4 0 4 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.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: Anita Jane`s Lodge 126/128 Uppingham Road Leicester Leicestershire LE5 0QF 01162768071 F/P01162768071 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) : Samalodge Limited care home 16 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Additional conditions: 16 The home may continue to accommodate a named person who falls within category LD as detailed in variation application number 49808. Date of last inspection Brief description of the care home Anita Janes Lodge is a care home providing care for sixteen adults with mental health difficulties, in addition it provides a respite service (short stay) for up to one service user and offers a day care service. There are eight single and four shared bedrooms all without en-suite facilities, located on the ground and first floor. There are bathing/showering and toilet facilities on both the ground and first floor. Communal areas consist of a lounge and dining room/recreational room and kitchen on the ground floor. Anita Janes Lodge has a large rear garden, which incorporates a patio area. Information about the service can be found on site in documents referred to as the Statement of Purpose and Service Users Guide. Care Homes for Adults (18-65 years) Page 4 of 29 2 4 1 1 2 0 0 8 Brief description of the care home A copy of the latest published report from the Commission for Social Care Inspection can be found in the entrance lobby. Fees at the home are currently £309 per week. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support peterchart Concerns, complaints and protection Environment Staffing Conduct and management of the home Poor Adequate Good Excellent How we did our inspection: This inspection visit took place on a weekday between 10:10 and 15:40. We focused on how three people who live at Anita Janes Lodge are supported by looking at their support plans and speaking to two staff members on duty about their understanding of these peoples needs. We spoke with two of the people, one in some detail about their impressions of living in the home. We also spoke with two other people who live in the home. We looked at two staff members recruitment and training records and discussed with them their experiences of induction, working in the home and how they made sure people living in the home are kept safe. Care Homes for Adults (18-65 years) Page 6 of 29 We looked at all communal areas of the home and some peoples bedrooms and looked at records relating to fire safety, safe working practices and quality assurance. We also looked at a report that the fire officer had made about his visit to the home in January. In addition to information collected at the inspection visit, this report has also been informed by the following sources: Information collected at a random inspection of the service, which took place on 24th November 2008. During that visit we were accompanied by an expert by experience (someone with direct experience of a similar services) who spoke to people about their experiences of living at Anita Janes Lodge. The Annual Quality Assurance Assessment (AQAA), a self assessment of how well the service is maintaining and improving the quality of outcomes for people living in the home. It also gives us some statistical information about the service. Three responses to surveys sent to ten people living in the home and one response to the five surveys sent to staff. Information about incidents in the home and how the service has responded to these. This also includes discussion with agencies who place people within the home such as the local authority. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are needed in assessment to ensure that the service is suitable to meet peoples needs before they move in. Evidence: Assessments from placing authorities were in place for two of the people whose files that we looked at. The person who had come to live in the home most recently did not have a Community Care Assessment, although some information about the persons needs had been given to the home by the placing social worker. The registered manager had not completed their own assessment of the persons needs, before they came to live at Anita Jane Lodge as the placement had been made in an emergency. Care Homes for Adults (18-65 years) Page 10 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs and aspirations are reflected in their support plans and they are supported to make choices about their lives. Staff waste time recording unnecessary information about needs that people do not have. Evidence: We looked at three peoples support plans and spoke to staff members on duty about their understanding of these peoples needs. We were also able to speak directly to one of the people about how their needs were met and very briefly to another person. Support plans contain a great deal of information, not all of which is relevant to meeting peoples needs. This is primarily because the template currently in use is based on the National Minimum Standards for Older People and includes such information as falls risk assessments and pressure area care assessments. This information is not relevant to the needs of the people currently living in the home who are predominantly adults under 50 without significant additional physical needs. This Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: concern re the services support plans was raised with the registered provider at the random inspection in November 2008. The Provider felt that the repetition of information consolidated staffs understanding of peoples needs. However we feel that staff are wasting time completing unnecessary records, which do not enable them to focus on peoples actual needs. Support plans do contain the necessary information but it is difficult for staff to identify and access this among the unnecessary information that is recorded. One persons support plan had been re-written, not using a template but simply writing down the persons identified needs and how they should be met by staff. This was clearly expressed and easy for both staff and residents to understand. All support plans should be written in a way that enables staff to offer consistent support to meet peoples identified needs. Risk assessments are in place for peoples, specific identified needs. Again the major concern was the accessibility of this information to staff. The registered manager expressed concern about her own and staffs ability and understanding of risk assessment practice and it is recommended again that she and key staff members attend training in this area of practice. People are able to make decisions about their day to day lives, when to go out and what to eat and drink. Two people who responded to our survey said that they always made decisions about what they do each day, one said that they usually did. All three said that they could do what they wanted during the day, in the evening and at weekends. Staff support them in achieving some of their choices, such as getting involved in further education courses. The registered manager has contacted a local advocacy service and has asked them to speak to people living at the home, at one of their meetings, so they have an understanding of the service on offer. Care Homes for Adults (18-65 years) Page 12 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to develop the skills of daily living. A good variety of food is served meaning that people have access to a well balanced diet. Evidence: People have been supported to extend their regular day time activities by visiting specialist day centres and taking part in further education. One person told us I feel more settled now and better about living here since they had been attending the day care setting more regularly and they were also hoping to start a computer course. Although other people living in the home also attend the same setting, some people, through choice have no formal activity during the day, preferring to visit local shops, cafes and walk in the local park. Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: Records show that a good range of food is served, which takes account of peoples likes and cultural needs. The main meal is served in the early evening to accommodate those that attend day services or other activities during the day. People said that the food was good. A record of each persons diet is kept as part of their daily notes and support staff explained how they monitor certain peoples food and fluid intake, if they have a particular need in this area. Some people are involved in cooking and shopping and people have the opportunity to do their own laundry if they wish. At the random inspection of the service in November, people said that they felt encouraged rather than told what to do. People also commented at this inspection that they would like a greater range of drinks and snacks to be available rather than just tea and coffee. This has now been provided. People living at Anita Jane Lodge have a range of different routines. Some people sleep a lot during the day and like to stay up late at night. Staff said that they frequently spent a lot of time talking to people in the evenings and during the night. Family and friends can visit at any time and staff support people to maintain contact with their families through phone and visits. Care Homes for Adults (18-65 years) Page 14 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health and personal care needs are met. Evidence: People receive various levels of support with their personal care and this information is contained within their support plans. Staff were able to give information about the kind of support that they give to different individuals. People living in the home have a variety of physical and mental healthcare needs. One person was supported by a staff member to access their Consultant on the day of the inspection, another person was visiting their Community Nurse independently. One person now administers their own medication independently and two other people are being actively supported in working toward this. Staff are liaising closely with other professionals in enabling this. Other people in the home receive full support with managing and administering their medication. This suggests that staff are able to vary the degree of support which they offer, dependent on the persons individual needs. All people living in the home have access to a chiropody service offered at the local Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: health centre; the centre also meets many of their physical health care needs, including management of long term conditions such as diabetes. Staff have received training in understanding peoples mental health conditions and training has been arranged in understanding diabetes to enhance their ability to support the people with this condition who live in the home. Suitable arrangements are made for people to access dental and optical services. Staff administering medication have received refresher training since the previous key inspection. There were no gaps in medication administration records and documentation relating to medication received into the home and returned to the pharmacist was in good order. Following advice from their recent training, blister packs are no longer used and all medication is given directly from the individually labelled bottles dispensed by the pharmacist. The staff member on duty said that this made them think much more actively about what they were doing. There were no excessive stocks of medication and the date when medication was opened was recorded on the individual container. Suitable storage for controlled medication is yet to be put in place to comply with changes to the Misuse of Drugs and Misuse of Drugs (Safe Custody Amendment) Regulations 2007. The registered provider should consult with the homes dispensing pharmacist to confirm that the cabinet he has purchased meets the necessary requirements. Records for controlled medication are in good order and the balance of medication was checked and found correct. Care Homes for Adults (18-65 years) Page 16 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples concerns are listened to and they are protected from abuse. Evidence: The Complaints procedure is displayed in the home and the three people who responded to our survey said that they knew how to make a complaint and that staff listened to them and acted on what they said. At the random inspection of the service people commented that they felt safe in the home. The registered manager has contacted a local advocacy service and is trying to arrange for them to speak at a residents meeting about their services. Residents meetings are held monthly and give people the opportunity to comment on the running of the home. The registered manager and all staff have received training in safeguarding vulnerable adults and staff members spoken with displayed a good understanding of whistle blowing and their responsibilities under the services policy in this area. Recent safeguarding concerns had been dealt with appropriately but the registered manager required some clarification as to the responsibilities of some agencies within the safeguarding process. It is recommended therefore that she seek some additional training in this area. Some people living in the home receive support with managing their finances. A record is kept of each transaction, together with any receipts. The balance of monies held is Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: regularly checked and two people sign for each transaction. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to the decor and fittings of the home would enhance the quality of peoples living environment. The home does not currently meet the requirements of the local fire authority, placing people living in the home at unnecessary risk. Evidence: Improvements to the rear garden noted at the previous key and random inspection have continued and this is now an attractive place to sit and there is scope for people living in the home to grow their own vegetables and flowers. The registered manager has requested additional garden furniture and a barbecue so that the area can be used for more social activities. The interior of the house was clean and fresh smelling and all toilets and bathrooms were equipped with soap and towels. Staff have received training in infection control and have a good understanding of how to maintain hygiene in the home. The registered manager has identified improvements to be made to bathrooms, including new floor covering (in some bathrooms this is worn or split), re-decoration and the provision of blinds for the windows. Tiles have been replaced in some Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: bathrooms but because of the age of the originals, these do not match. The carpet in the hall, stairs and landing requires cleaning and walls in this area require cleaning and/or redecoration. The registered manager has tried to introduce some homely touches but there is still work to be done in this area, such as fitting lampshades to bare light bulbs. Improvements such as this would make the physical environment a more pleasant place to live and may impact positively on peoples sense of wellbeing. Four Requirements were made by the fire authority during their visit on 9th January 2009. No arrangements have been made to meet these requirements. They must be complied with to ensure the ongoingsafety of people living in the home. All fire doors need to be checked and adjustments made were necessary to endure that every door fits and closes correctly. Fire stopping is required in some areas and fire warning systems need improvement in the loft area of the home. Please see the outcome group relating to the conduct and management of the home for the requirment relating to the homes fire risk assessment. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are effectively supported by well-trained staff Evidence: We looked at the recruitment information for the two most recently appointed staff. Two written references and Criminal Records Bureau checks had been obtained before they started work and their names had been checked against the vulnerable adults register. These checks make sure that only suitable people work at Anita Janes Lodge. People living in the home said that staff were more accessible now that their office had been moved into the corner of the main dining/activities room. Staff also said at this and the previous visit to the home that the siting of the office made it easier for them to support people and monitor their wellbeing. The registered manager continues to work with Leicester City Council Development Unit to ensure that staff receive ongoing training that enables them to carry out their role effectively. The staff member who responded to our survey said that they received training that kept them up to date with current practice and enabled them to meet peoples needs. Most staff have received training in understanding mental health conditions and this is to be arranged for the two staff who have recently started work, although they do have previous, relevant experience in this area. These staff are currently undertaking their induction Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: training and have also received training in effective communication, the principles of good recording and equality and diversity. Seven staff members have obtained National Vocational Qualifications at level 2 or above and all senior staff and some care staff are working to wards their level 3 qualifications. Documentation and discussion with three staff members confirmed that they receive regular one to one supervision from the registered manager and have the opportunity to discuss their work with her. The staff member who responded to our survey said, If we need to talk or have any problems, [the registered manager] is always there for us.. 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. Peoples views, although gathered, are not systematically used to improve the quality of the service. Concerns raised about health and safety are not always responded to in a timely fashion. Evidence: The registered manager is currently undertaking a level 4 National Vocational Qualification in care and support and has completed a supervisory and leadership course. She also continues to participate in additional training to ensure that she remains up to date with current practice. Although systems are in place to survey stakeholders opinions of the service (this includes people living in the home as well as community nurses and general practitioners), a system to use this information to inform how the home is run and develop the service is yet to be put in place. Quality monitoring and the development of the service is still heavily reliant on meeting requirements and recommendations set Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: by the Commission. Discussion with the manager about some of the documentation that is being completed indicated that often this was being done because the Commission required it rather than as a way of improving the service. Misinterpretation about what is required has led to some unnecessary documentation being completed and a belief that this in itself is the objective rather than seeing appropriate documentation and recording as a means of ensuring a consistently well run service. The provider or his representative visits the home on a regular basis (usually weekly) this was confirmed through discussion with staff and people living in the home. Copies of reports of visits were also seen. Staff have received training in fire safety, first aid and food hygiene. Risk assessments were being updated during the inspection for safe working practices in the home. The fire authority made a formal inspection of the service on 09/01/09 and made several requirements. No action had been taken to meet these. Requirements relating to fire doors, fire stopping and fire warning systems have been dealt with in the Environment Outcomes section of this report. The current fire risk assessment was also said to insufficiently detailed and this must be re-assessed to ensure the ongoing safety of people living in the home. Care Homes for Adults (18-65 years) Page 24 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 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 2 14 The registered provider must ensue that a suitable assessment of a persons needs is obtained, before they come to live in the home. This is to ensure the service is able to meet peoples identified needs before they move into the home. This practice also helps to ensure that a new persons needs do not impact negatively on the people already living in the home. 31/05/2009 2 20 13 Secure storage must be put in place for controlled drugs To meet the requirements of the Misuse of Drugs and Misuse of Drugs (Safe Custody Amendment) Regulations 2007 Original timescale of 31/03/02009 not met. 30/04/2009 Care Homes for Adults (18-65 years) Page 26 of 29 3 23 23 The registered provider must ensure that all fire doors fit and close correctly. To comply with the requirements made by the fire authority and to ensure the ongoing safety of people living in the home. 15/05/2009 4 23 23 The registered person must ensure that appropriate fire stopping is put in place in the areas identified by the fire authority in their visit of 09/01/2009 To comply with the requirements made by the fire authority and to ensure the ongoing safety of people living in the home. 15/05/2009 5 23 23 The registered person must ensure that appropriate fire warning systems are fitted throughout the home. To comply with the requirements made by the fire authority and to ensure the ongoing safety of people living in the home. 15/05/2009 6 23 23 All floor coverings in the home must be reasonably clean and in good repair. So that people live in an environment which is safe and promotes their sense of well-being. 31/07/2009 7 42 13 The registered provider must ensure that the fire risk assessment is updated. 31/05/2009 Care Homes for Adults (18-65 years) Page 27 of 29 This is to meet the requirements of the local fire authority and to ensure the ongoing safety of people living in the home. 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 6 Support plans should be written in a format that is easily understood by both staff and the person themselves and should contain information about peoples actual needs and the way they should be met. The registered manager and staff members should undertake training in risk assessment and management. The registered manager should seek additional training in safeguarding to clarify different agencies roles within the safeguarding process. 2 3 9 23 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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