Inspection on 26/05/09 for Avondale

This inspection was carried out on 26th May 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avondale 21/05/07

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Avondale 6 - 7 Nelson Terrace Redcar TS10 1RX 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: Stephen Ellis Date: 2 6 0 5 2 0 0 9 This report is a review of the 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 stars – excellent  2 stars – good  1 star – adequate  0 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. 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 Care Homes for Adults (18-65 years) Page 2 of 38 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 38 Information about the care home Name of care home: Address: Avondale 6 - 7 Nelson Terrace Redcar TS10 1RX 01642494509 F/P01642494509 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) : Potensial Limited care home 12 Number of places (if applicable): Under 65 Over 65 65 0 learning disability Additional conditions: Date of last inspection 2 1 0 5 2 0 0 7 A bit about the care home Avondale is registered as a care home for up to twelve people with a learning disability. The Victorian building is two Page 4 of 38 Care Homes for Adults (18-65 years) houses which are linked and they are as one home. All bedrooms are for single occupancy and have en-suite shower and toilet facilities. The home has large communal rooms and there are: a dining room, three lounges, a kitchen, bathing facilities and four bedrooms on the ground floor and eight bedrooms on the first floor. There are small gardens to the front of the house that overlook Redcar cricket field. The home is close to the sea front and the main shopping area. The fees charged to people who use the service range from £635 Care Homes for Adults (18-65 years) Page 5 of 38 to £2000 per week, but the actual amount payable depends on peoples individual circumstances Care Homes for Adults (18-65 years) Page 6 of 38 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 Care Homes for Adults (18-65 years) Page 7 of 38 How we did our inspection: This is what the inspector did when they were at the care home This key inspection was carried out on 26th May 2009 and was informed by the homes Annual Quality Assurance Assessment, which it completed on 20th April 2009. The last key inspection took place on 21st May 2007. At the time of inspection there were nine people who use the service living at the home. Most took part in the inspection, including seven who returned surveys to the inspector. The inspection included a tour of the building, discussions with 3 people who use the service, 2 staff, manager and area manager who was visiting at the time, Care Homes for Adults (18-65 years) Page 8 of 38 plus examination of a sample of records that the home is required to keep, such as care plans, maintenance and medicine records. The weekly fees range from £635 to £2000, but the actual amount people pay depends on their individual circumstances. What the care home does well The service respects the individuality of each person who uses the service and consults fully with them about their needs, wishes and aspirations. Typical comments from people who use the service include: The staff always treat me well. There are good policies and Care Homes for Adults (18-65 years) Page 9 of 38 procedures, reinforced by good staff training, that guide the skilled work of staff in supporting people who use the service. Plans of care are comprehensive and detailed, with a person-centred focus, and are regularly reviewed. People who use the service lead varied and satisfying lifestyles. They have opportunities for good links with families, friends and the wider community. They exercise choice in their daily lives and the service helps them maximise their independence. The accommodation is spacious and potentially of a good standard (for example, all bedrooms are singles with en suite toilets and shower facilities) but poor maintenance has allowed the Care Homes for Adults (18-65 years) Page 10 of 38 standard of provision to fall to an unacceptable level, in terms of health and safety and the dignity of people who use the service. There is a well-trained and experienced staff team and each person who uses the service has a key worker who works closely with each individual to help him or her achieve personal goals. The home is well run (with the exception of maintenance) with an experienced management team, including a new manager. The service has a continuous improvement plan that is reviewed and updated monthly (although action is overdue with regard to maintenance and repairs). Care Homes for Adults (18-65 years) Page 11 of 38 What has got better from the last inspection A new manager has been appointed. Documentation used in the service has been computerized, helping to improve the quality assurance process. The service has connected to broadband, helping to improve the computer system. Greater choice in social and recreational activities has been established following consultation with people who use the service. Care plans have been improved by including a monthly summary reflecting the views and aspirations of people who use the service. The complaints procedure has been enhanced Care Homes for Adults (18-65 years) Page 12 of 38 by use of pictorial information. New lounge and dining furniture has been obtained. What the care home could do better The homes medication procedures need to be followed at all times, especially when hand-writing medicine profiles and quantities into the medication administration record. There are numerous environmental issues concerning maintenance, repair and replacement, plus extensive redecoration, which must be attended to promptly, in the interest of health and safety and the dignity of people who use the service. The new Care Homes for Adults (18-65 years) Page 13 of 38 manager is required to apply for registration. 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 Stephen Ellis St Nicholas Building St Nicholas Street Newcastle upon Tyne Tyne and Wear NE1 1NB 01912333300 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 14 of 38 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 15 of 38 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. The needs and aspirations of people who are considering using the service are thoroughly assessed and acted on wherever possible. Evidence: Seven people who use the service said that they felt they had enough information about the home before they moved in. They felt they could make a positive choice, having had introductory visits and opportunities to meet and talk with other people who use the service, and staff. They felt that their needs were well understood and the service they had received since admission supported that view. They felt that their care needs were well met. This view was reinforced by the 3 support plans of care examined on the day. These showed that detailed and comprehensive assessments of need were completed prior to admission and had been kept under close review ever since. The service provided is accurately described in the homes statement of purpose and service users guide, which are available in accessible formats. Care Homes for Adults (18-65 years) Page 16 of 38 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 individual needs and choices are well assessed and acted on, so that people who use the service are supported in their daily lives and decision-making and encouraged to take responsible risks to maximize opportunities for personal fulfillment. Evidence: Three plans of care were examined and found to be comprehensive and detailed in all the areas of daily life where people required support. They were person centred in their focus on the individual identity of each person using the service. Staff training in this aspect of care planning is on-going, with further training proposed for 2009/10. People who use the service made comments about the quality of care planning, decision making and risk taking. Typical comments included: I always make decisions about what I do each day, with help from my family and carers. I can do what I want to do during the day and at the weekend. The staff always treat me well. People were encouraged to take responsible risks and these were found to be well documented in individual plans of care, including detailed assessments of risk and means by which risks could be minimized without adversely affecting peoples right to choice and independence. Care Homes for Adults (18-65 years) Page 17 of 38 Care Homes for Adults (18-65 years) Page 18 of 38 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. The service helps to promote person centred lifestyles that provide opportunities for independence, choice, social inclusion and fulfillment. Evidence: Most people who use the service said that they were happy with the lifestyles they had developed since moving to this home. They were able to take part in educational and leisure activities appropriate to their needs and interests, both in and out of the home. For example, six people go to day support services, as well as people enjoying walks out and outings locally (for example, in Redcar, Flamingo Land and Whitby) in-house art and craft work, plus bowling and shopping trips. Staff said that they always tried to support people in ways that they preferred and took care to ensure that people were fully consulted about their choices. For example, holidays were planned on an individual basis, taking into account the views and wishes of people who use the service and their families. These consultations and support arrangements were well documented in individual care plans. Typical comments from people who use the service included: The Care Homes for Adults (18-65 years) Page 19 of 38 Evidence: carers always listen and act on what I say. Key workers try to support people who use the service in individual ways so that each person can have some quality time each week doing things of their choice with the support of their key worker. Care Homes for Adults (18-65 years) Page 20 of 38 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. The health and personal care of people who use the service is based on their individual needs and wishes. The principles of respect, dignity and privacy are put into practice. The management of medication is generally sound, based on good policies and procedures, plus supportive staff training. Evidence: Comments received from seven people who use the service were positive and complimentary about personal support and healthcare arrangements. People felt their personal care needs were met with sensitivity and understanding by a dedicated staff team. People who use the service said that their individuality was respected and their wishes were supported wherever possible. There were good relationships with all members of staff, especially key workers, who have a special relationship with the individual person who uses the service. People who use the service felt they understood their plans of care and were involved in reviewing them with staff. Typical comments included: The staff always treat me well. They also felt satisfied with their healthcare arrangements, saying that the doctor or nurse would see them whenever required. Plans of care confirmed detailed records of healthcare needs and interventions by medical practitioners. They also addressed the following issues: personal profile and photograph, plan of care, protocols for delivering care, risk assessments, progress reports, incident reports, ABC Charts, meetings, medication profiles, appointments, correspondence, Care Homes for Adults (18-65 years) Page 21 of 38 Evidence: therapists involvement, contracts, mobility, weekly timetable, daily living assessment, pen pictures, Activities of Daily Living, Behaviour Charts, Mood Chart, Health record, weight record, key worker summaries, and Person Centred Planning matrix. The home is trying to promote healthy eating and lifestyle choices, whilst always respecting individual preferences and decisions about these matters. The arrangements for medication were found to be generally good, with good storage, administration and disposal procedures. Also, all members of staff responsible for medicines at the home have undergone Safe Handling of Medicines Training and have periodic competency assessments. It was noted that some handwritten entries in the Medication Administration Record (MAR) sheets had not been fully checked and countersigned. However, these were the exception rather than the rule. The manager confirmed that all staff members had completed competency assessments over the past 6 months, and accredited training in the safe handling of medicines was planned for later in 2009. Care Homes for Adults (18-65 years) Page 22 of 38 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. People who use the service have access to a robust, effective complaints procedure and are protected from abuse. Evidence: People who use the service said they were confident about being able to complain should the need arise. They felt able to talk to any of the staff about any concern or complaint they might have. Staff members said they had undergone training in protection of vulnerable adults and whistle blowing and would not hesitate to alert the appropriate authorities to any suspicion of abuse or neglect, in keeping with the Providers policies. Each person who uses the service has been given a copy of the homes complaints procedure in accessible format. People who use the service are frequently reminded that the service welcomes their concerns or complaints and promises to take those seriously and investigate them thoroughly, involving the Local Authority safeguarding procedures wherever appropriate. Thorough pre-employment checks are carried out on all staff, including enhanced Criminal Record Bureau checks, Protection of Vulnerable Adult register checks and the taking up of two written references. Both internal and external management monitor any complaints, compliments and general comments very carefully, as documented in the homes complaints and compliments file. Care Homes for Adults (18-65 years) Page 23 of 38 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. The service has not been well maintained, so that a number of issues have developed concerning health and safety that must be addressed in the near future. Evidence: There were many issues of concern, as identified in the managers operational report (26/05/09), the weekly site report completed by the manager (week ending 22/05/09) and in the reports of the regulation 26 visits completed by the area manager (29/01/09 and 13/03/09). These issues of concern are summarized in a property audit report completed by the home manager and area manager (May 2009). The report identifies an extensive list of deficiencies that were confirmed during the inspection, ranging from redecoration of most of the premises, to repair and refurbishment of significant parts of the home, to bring the building up to an acceptable standard. Key issues are identified in the requirements section. Although the home is generally clean, with attention being paid to infection control, there are areas that require attention, including fungal spores in some en suite bathroom areas and one mattress that requires replacement. Nonetheless, the home did well to receive 4 stars from the local environmental health authority for its kitchen hygiene. Care Homes for Adults (18-65 years) Page 24 of 38 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. Staff members are trained, skilled and in sufficient numbers to fulfill the aims of the home and the changing needs of people who use the service. Evidence: People who use the service said that they got on well with staff and were involved in the recruitment process, helping to select suitable people to work at the home. Staff members confirmed that people who use the service were involved in recruitment. An examination of staff files confirmed that staff members are only appointed after careful checks and references have been taken up, including enhanced Criminal Record Bureau checks. They undergo a comprehensive induction period (normally 3 months) to equip them with essential skills and knowledge so that they can do their work safely. All mandatory subjects are covered, including moving and handling, food safety, infection control and fire safety. In addition, values and principles of care are explored in depth. The training provided is wide ranging and there is on-going training needs assessments for each member of staff. Three staff members confirmed the nature and quality of their training, as evidenced in staff files. Over 75 of staff members have achieved National Vocational Qualifications (NVQ) in Care at level 2 or above, and a good proportion of staff members are working towards achieving NVQ level 3 in Care. Most staff training is compatible with the Learning Disability Initial Award or equivalent, ensuring it is focused on the needs of people who use the service. Staffing levels were found to be appropriate Care Homes for Adults (18-65 years) Page 25 of 38 Evidence: for the needs of the nine people being accommodated (maximum of 12). Typically, during the day, there are 3 members of care staff on duty from 8 am to 12 midday, then 2 care staff from midday to 3 pm, followed by 4 care staff from 3 pm to 8 or 9 pm, then 2 care staff to 10 pm. At night, from 10 pm to 8 am, there are 2 staff members on duty, one of which is on call on the premises between midnight and 6 am. Staffing levels are carefully monitored and vary in accordance with the number of people on the premises and their dependency needs. Staff members felt that the numbers on duty were about right, and this was reflected also in comments made by people who use the service. Care Homes for Adults (18-65 years) Page 26 of 38 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 management and administration of the home is based on openness and respect, with partially effective quality assurance systems implemented by an experienced manager and wider management team. The manager is required to apply for registration. Evidence: The home is adequately run, with monthly team meetings of staff, regular key worker meetings with people who use the service and monthly visits from an Area Manager. Records of these meetings and visits are kept. The newly appointed, but unregistered, manager has substantial experience in the field of working with people with learning disabilities at a senior level, and is planning to register for the Registered Managers Award at National Vocational Qualification (NVQ) level 4. She already holds NVQ level 4 in Care, along with other relevant qualifications. She is required to apply to be registered as manager. Each month the service receives a visit from a senior manager to check on how well the home is doing. Surveys are carried out annually, inviting feedback from people who use the service and their representatives. The home acts on these results wherever possible, by incorporating proposed actions into the homes continuous improvement plan. The one area where the home has not made progress concerns the maintenance and repair of the premises and urgent action is required to bring material conditions up to Care Homes for Adults (18-65 years) Page 27 of 38 Evidence: an acceptable standard. The service has well developed policies and procedures to guide staff in all areas, in the best interests of people who use the service. Full health and safety checks are carried out at regular intervals and reported on, so that progress can be monitored, although necessary action has not always been taken by the registered provider with regard to maintenance issues that have been identified by the manager and wider management team. People who use the service expressed confidence in the management of the home and valued the fact that they were regularly consulted about all key matters. Care Homes for Adults (18-65 years) Page 28 of 38 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 Care Homes for Adults (18-65 years) Page 29 of 38 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 20 13 Hand written entries onto 31/07/2009 Medication Administration Records must have full details of quantities and date received, plus signatures and countersignatures of the staff responsible for entering the details and confirming that they are accurate. The possibility of recording and/or drug administration errors is reduced by following the procedure outlined in the requirement. 2 24 23 All of the issues identified in 31/07/2009 the reports of the homes manager and area manager in May 2009 must be fully addressed by way of risk assessment, prioritization and action plan. This should be submitted to the inspector before the end of July 2009. Care Homes for Adults (18-65 years) Page 30 of 38 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 The extent and nature of the material issues concerning the safety and suitability of the building require a comprehensive plan of action that must be shared with the regulator at the first opportunity in the interests of the safety and welfare of people who use the service. 3 24 23 The roof and guttering require repair in many places. 09/10/2009 The home must be watertight and the roof and guttering require extensive repair to achieve this objective. 4 24 23 Floor covering throughout the building must be assessed for quality and safety so that there are no tripping hazards caused by ill-fitting carpeting or floor covering. 09/10/2009 Floor covering must be risk assessed and action must be taken to minimize the risk of tripping. 5 24 23 Suitable locks need to be fitted throughout the home, including suitable and safe bedroom door locks and external door locks that do 09/10/2009 Care Homes for Adults (18-65 years) Page 31 of 38 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 not require a key to be opened from the inside in the interest of fire safety. If in doubt, the provider must consult with the fire safety officer for advice and guidance. All locks fitted must be safe and fit for purpose so that people who use the home have privacy, choice and dignity as well as safety. Fire exit doors must comply with fire safety regulations so that evacuation is not impeded by the type of lock fitted. 6 24 23 09/10/2009 External doors and porch doors need to be refitted so that they operate and close fully. They also require redecoration and it may be better to replace them rather than carry out repairs. External and porch doors need to operate and fit correctly, in the interests of security and comfort. They need to be decorated in a manner that promotes the dignity of the people who use the home. 7 24 23 Glazing within the home must be risk assessed and may require safety glass or other action to be taken to minimize the risk associated 09/10/2009 Care Homes for Adults (18-65 years) Page 32 of 38 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 with type and location of glazing fitted. For example, porch and cabinet glazing will need to be risk assessed and appropriate action will need to be taken. To minimize the risk associated with the hazard of ordinary glazing within the home. 8 24 23 Windows throughout the 09/10/2009 building need to be checked and repaired/replaced where necessary, so that they are water-tight and do not permit draughts. A number of windows do not fit or close properly, allowing draughts and water to penetrate the home. 9 24 23 The kitchen requires new light fittings as they are ineffective as a source of light, and several of the lights do not work when a new bulb is fitted. 09/11/2009 Good lighting is required in the kitchen for its safe operation when natural light is insufficient. 10 24 23 The bath hoist in the communal bathroom is not safe and has been 09/09/2009 Care Homes for Adults (18-65 years) Page 33 of 38 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 condemned. A new one is on order, but this should be expedited. The current hoist is not safe to use. 11 24 23 Bedroom 5 requires a new mattress. 06/08/2009 The existing mattress is badly stained. 12 24 23 The gas central heating requires attention as there are a number of areas in which the radiators do not work, including the middle lounge, the hallway towards the laundry from the dining room, in the communal bathroom and several bedrooms. 09/10/2009 The central heating needs to work throughout the home to deliver the correct temperature in all rooms. 13 24 23 The stair lift requires repair or replacement. 09/10/2009 The stair lift is unreliable and people with mobility problems need to have access to all parts of the building. Care Homes for Adults (18-65 years) Page 34 of 38 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 14 24 23 The back door is rotten in places and ill-fitting, with putty missing from parts of the glazing. It must be replaced or repaired. 09/10/2009 The premises must be safe and secure, and free from ingress by external elements. 15 24 23 The gas pressure needs to be 09/10/2009 adjusted so that the gas oven and gas central heating can be used simultaneously. Gas pressure needs to be adjusted so that the central heating and oven can be used together, as at present, only one or the other may be used at any one time. 16 24 23 All bedrooms require 09/10/2009 attention to ensure that they are free from damp, that all windows are rot-free, operate properly and are free from draughts and have restrictors fitted, that radiators work properly and their covers are securely fitted, that wall-mounted convector heaters are fully risk assessed and made safe, that all bedrooms are supplied with furniture and bedding in good condition, that all bedrooms have door closers that comply with fire Care Homes for Adults (18-65 years) Page 35 of 38 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 safety regulations, that all bedrooms are reasonably decorated, that all en suite bathrooms are free from damp and mould, have safe shower doors and showers that are fully operational within safety limits, have hot and cold water supplies that are fully operational, have floors that are of sound construction and supplied with non-slip flooring, that all toilet seats are fitted securely, that all walls and ceilings in en suite bathrooms and bedrooms are sound and do not let in water nor draughts. To ensure that bedrooms and en suites are safe, comfortable and convenient to use, promoting peoples safety and dignity. 17 37 8 The service is required to 10/09/2009 have a registered manager and the new manager should apply for registration. The service is legally required to have a registered manager. Care Homes for Adults (18-65 years) Page 36 of 38 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 37 of 38 Helpline: Telephone: 03000 616161 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) 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. 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