Inspection on 22/10/08 for Beechcroft, Cheltenham

This inspection was carried out on 22nd October 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beechcroft, Cheltenham 29/08/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Beechcroft, Cheltenham 295 Gloucester Road Cheltenham Gloucestershire GL51 7AD two star good service The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Lynne Bennett Date: 2 3 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to:  Put the people who use social care first  Improve services and stamp out bad practice  Be an expert voice on social care  Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Internet address www.csci.org.uk Information about the care home Name of care home: Address: Beechcroft, Cheltenham 295 Gloucester Road Cheltenham Gloucestershire GL51 7AD 01242226960 TBC amy.ranger@orchardendltd.co.uk 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) : Orchard End Limited care home 4 Number of places (if applicable): Under 65 Over 65 4 0 learning disability Additional conditions: The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) The maximum number of service users who may be accommodated is 4. Date of last inspection A bit about the care home Beechcroft is a large detached house in the middle of Cheltenham near to local amenities and facilities. It is one of six registered homes owned by Orchard End Ltd a subsidiary of CHOICE. The home provides spacious accommodation for four people with a learning disability and can accommodate one person on the ground floor with additional physical disabilities. Each person has a bedroom with an en suite which includes either a bath or shower. Communal areas include a lounge and separate dining room, large kitchen and sensory room. The Statement of Purpose and Service User Guide are displayed in the entrance hall and copies are available from the office. Fees for the home are assessed on each persons individual needs in arrangement with their placing authority. Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home How we did our inspection: This is what the inspector did when they were at the care home This inspection was completed in October 2008 and included two visits to the home by one inspector on 22nd and 27th October. The registered manager was present during the second visit to the home. The registered manager completed an AQAA (Annual Quality Assurance Assessment) for an annual service review of the home in August 2008, providing information about the service and plans for further improvement. It also provided numerical information about the service (DataSet). Feedback had been received for this review from parents and staff working at the home. We (The Commission for Social Care Inspection) spent time observing the care provided to all people living in the home. We also talked to five members of staff about the care they provide. The homes group manager was present during the first visit to the home. A selection of documents were examined including care plans and other related records, staff files, quality assurance report and health and safety systems. What the care home does well What has got better from the last inspection Five requirements were issued at the last inspection and these had all been complied with. Risk assessments had been put in place to minimise any risks to people using equipment in the garden. The complaints procedure had been displayed in peoples rooms and was produced in a format appropriate to peoples needs. Records required by us when recruiting new staff had been obtained prior to employment. A quality assurance system had been put in place which involved feedback from people living in the home and their relatives. Health and safety checks were in place and being carried out regularly. What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Lynne Bennett Colston 33 33 Colston Avenue Bristol BS1 4UA 011 7930 7110 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People have access to information they need enabling them to make a decision about whether they wish to live at the home, although these documents are not as up to date as they could be. A comprehensive assessment of the persons wishes and needs are taken into consideration before offering them a place. Evidence: The home had a Statement of Purpose and Service User Guide which had been produced in a format making good use of photographs, text and pictures. These documents were produced in 2006 when the home opened and will now need reviewing. Three people had moved into the home since the last inspection. Each had the opportunity to visit the home prior to moving in and was supplied with information about the service they may receive. All had copies of a comprehensive assessment completed by Choice which was supplemented by assessments and current care plans from placing authorities. Additional information had been supplied from previous placements and relatives. There was evidence that people had three month placement reviews with their placing authority. Each person had a copy of the terms and conditions in place with Choice which they had signed where appropriate with countersignatures by the registered manager and their representative. 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 . People live in a home which is run in their best interests offering them choice, respecting their wishes and keeping them safe. Evidence: The care for three people was case-tracked and another file sampled. Each person had an assessment of their physical, social, emotional and intellectual needs in place providing a holistic overview of their wishes and goals. From these care plans, support guidelines and risk assessments were developed. There was evidence that changes to need were identified on the plans as they arose and corresponding changes made to other documents. Regular reviews were in place every six months internally and annually with representatives of placing authorities and/or relatives. Where appropriate people had signed care plans and risk assessments. The documents for one person referred to their former placement. A community care plan for the same person indicated that they used a handling belt but there was no reference to this in the risk management plan. The Area Manager stated that upon referral to the local Community Learning Disability Team they had decided this was inappropriate and reference to this had been removed from one document but mistakenly left in the other document. Staff spoken with had a good understanding of peoples needs and were observed following care plans and risk assessments. For instance one person liked to take their clothes off and care plans provided guidance about how to deal with this. Staff were observed sensitively and discreetly encouraging the person to dress using positive reinforcement such as a drink or activity afterwards. Staff confirmed that the person Evidence: would not be left to wander around without their clothes but that when in a heightened state of anxiety they may be left to calm down before being approached to get dressed. This was to avoid further escalation in line with their support guidelines. Visitors had commented that they had witnessed this happening. The registered manager stated that there was a protocol in place that when visitors come into the home staff ask them to remain in the hall until they have ascertained whether they can enter communal areas, thereby respecting the privacy and dignity of people living in the home. Staff followed this when admitting us to the home. The registered manager stated that different strategies had been tried such as alternative clothing and using a screen but these had not been successful. Episodes of removing clothing had reduced. Documents confirmed this. Each person had a communication profile which noted key words and described how staff should interpret their non verbal behaviour. Staff spoken with explained how they interpreted sounds people made and their responses to them. They were observed following these guidelines enabling people to express their needs and responding to them with patience and respect. Where care plans and risk assessments noted that a listening device was used the appropriate supporting documentation was in place such as a record of a best interests meeting, agreement and guidance. Restrictions to choices or freedoms were also recorded, such as occasionally locking the kitchen, securely storing some snack items and the use of a keypad on the front door. The rationale for these restrictions was clearly recorded. Any restrictions to liberty will need to be recorded in future in line with the forthcoming Deprivation of Liberty Safeguards. Risk management plans were in place alongside support guidelines which had been developed by a Pscyhologist with the staff team. Additional risk assessments had been developed with evidence that they were being regularly reviewed. A missing persons policy and procedure was supported by individual profiles of each person including a current photograph. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People have access to a limited range of activities outside of the home. Improvements in the availability of transport may improve this. People have a nutritional and healthy diet. Their diverse needs are catered for. Evidence: Care plans indicated peoples religious beliefs and ways in which they would like to be supported either by attending church or staff providing them with readings. Information had been provided for staff for one person who was a Jehovahs Witness. Their care plan gave clear guidelines about medical interventions. The registered manager confirmed that alternative arrangements were made when other people were celebrating religious festivals so that the person could do other activities if they chose not to join in. People were being supported in a range of activities both inside and outside the home. One person liked to go for drives and was heard asking to go out with staff during one visit. Unfortunately at the time they had no access to a vehicle which had been used to take another person away for a short break. Staff said that they were advised during the visit that they could use a local taxi firm. The registered manager later stated that a mini bus had been borrowed from another home to enable people to go out on two afternoons. Daily diaries indicated that a significant amount of time was spent for most people at home. Some like music or the television and all appeared to enjoy spending time in the sensory room. One person liked doing arts and crafts and there were examples of their work around the home. Another person had a tutor supporting them Evidence: each week and all had access to Vital Therapies each week. Staff said people liked to go out shopping and have lunch out occasionally. A senior member of staff was just about to start an activities course and said they would be taking over responsibility for reviewing activities for people. Activity outcome forms were in place which evidenced that one person had been supported to try out a local college but had shown no interest in the course attended. Another form stated that a person was supposed to go swimming but this had been cancelled because there was no transport. These indicated that a lot of time was spent in the home. The AQAA recognised this stating, We plan to continue to support service users in their choices of what they would like to do each day and to continue to introduce different activities to all service users. We will regularly review recreational and occupational opportunities with all service users living at Beechcroft House. Contact sheets were being kept evidencing visits to people. They indicated that relatives regularly visit the home. One person was on holiday with their parent during the visits. A small room was available to meet relatives in privacy if needed. Peoples rooms were being locked when they were not using them. People were observed choosing where to spend their time in communal areas, in their rooms or in the garden. They were observed helping around the home, taking out the rubbish and helping to make drinks. Menus had been developed to reflect the likes and dislikes of people living in the home. One person was being supported to monitor their weight and low fat recipes had been provided. Records were being kept of meals and fluids for each person. Thickeners were used for one person in their drinks and records were kept evidencing that this was being done. Staff said that people were having regular access to fresh fruit either in a salad or cut up into pieces. They were observed being offered this regularly throughout the day. 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 wellbeing are being met helping them to stay well. There are some improvements in the administration of medication that need to be implemented to safeguard people from the risk of error or possible harm. Evidence: Peoples care plans provided information about their likes and dislikes and included details of how they would like to be supported with their personal care. Care plans did not provide information about peoples preferences for the gender of staff providing their personal care. There was flexibility with peoples routines. They decided when they would like to go to bed or get up. One person had problems sleeping and staff provided support during the night when they were unable to sleep. This appeared to be significantly improving with the person starting to sleep through the night. Each person had a health action plan at different stages of completion. Additional healthcare records provided some information about appointments with their doctor or optician including a summary of the outcome. Not all appointments were entered on these records with some information being noted in dairies. For instance, there was no evidence that people were having access to dental treatment although an entry in a diary indicated an appointment had been made for one person. There was evidence of referrals to the local Community Learning Disability Team. A Psychologist employed by Choice worked closely with the home providing support guidelines and risk management plans. Individual medication profiles were in place with a current photograph of each person. Evidence: A monitored dosage system was being used and staff had completed training in the safe handling of medication. A current medication policy was in place. Administration records were satisfactory with handwritten entries being countersigned and staff initialling after medication had been given. A signature list was in place with a record of staff initials. Creams and liquids were labelled with the date of opening and a stock record was being kept for all medication. Tablets for one person were being administered covertly. A best interests meeting had been held and a protocol and guidance was in place. Advice had been sought from the Doctor and Pharmacist that medication could be given in this way. It became apparent during the visits that when one person went away for a period of social leave they took their medication with them in envelopes. These envelopes had been labelled with information as set out by the pharmacy with additional emergency information. This is secondary dispensing of medication and there must be robust procedures and guidelines in place when this happens. The home must make sure that they have a robust risk assessment in place, providing details about which staff are permitted to do this, what containers the medication is to be put in, how the containers are to be labelled and what other information is to be given. A clear record of the process at each stage must be kept. Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Systems are in place that enable complaints and concerns to be raised by people using the service or on their behalf. People are safeguarded from possible harm or abuse. Evidence: The home had a complaints policy and procedure in place which was produced in a version appropriate to peoples needs using text, symbols and pictures. In their surveys people commented, they knew how to make a complaint. The DataSet in the AQAA stated that the home had received 9 complaints since the last inspection. These had been processed in line with the organisations complaints procedures and one had been upheld. We (The Commission for Social Care Inspection) had received one complaint that we forwarded to the organisation to investigate. We had also been contacted by Environmental Health to discuss a complaint they had received about noise disturbances. They confirmed the complainant had not logged any further concerns with them. The group manager described the actions the home had taken to resolve these concerns including changes to the environment and guidance to staff when supporting people in the garden. The home were also holding an open day to invite neighbours and other people in the local community to look around the home and to meet people living there. Staff said that they had completed training in the safeguarding of adults and that they were confident that the registered manager and organisation would challenge poor practice and take appropriate action. One person had a difficult transition moving into the home and we had concerns about their welfare and the welfare of others living there. The registered manager and group manager kept us informed of how they were supporting this person and what actions they were taking to safeguard others living in the home and also protect the person from harm. Over the past four months there had been a significant drop in notifications to us which was confirmed by behaviour observation charts and incident records in the home. Staff spoke with confidence about the support they provided to this person to manage their anxiety and to help them avoid harming themselves and others. They were observed effectively following support guidelines and risk management plans during the visits. Evidence: Staff working in the home had done training in MORE (Management of Response to Emotion) which provided them with the knowledge and skills to support people in distress and to prevent their anxieties escalating. Risk assessments were in place for new staff who had not completed this training stating that they were not to be involved in the use of physical intervention. New staff confirmed this. Support guidelines and risk management plans clearly identified triggers which may upset people and suggested responses by staff. They stated physical intervention was to be used as a last resort. These documents were being regularly reviewed by the Psychologist who provided regular input at the home. The registered manager was monitoring behaviour observation charts indicating areas of good practice and where staff may need to reflect on their practice. Staff confirmed that where incidents had occurred they were offered debriefs with the registered manager. 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 . Pleasant accommodation is provided for people which could be improved by more attention to the cleanliness of some areas of the home and dealing with unpleasant odours. Evidence: The home provides spacious communal areas for people including a lounge and separate dining area, a small room with a sofa and a sensory room. The sensory room had been relocated to the ground floor and the registered managers office moved upstairs. The door handle to the lounge had plastic gloves wrapped around the handle. The group manager said this had been pointed out at a recent Regulation 26 visit to the home and they had been asked to remove it. It was being used to prevent the fire door from slamming shut. Other fire doors around the home did not close properly. During the first visit maintenance were called and asked to attend to the door. This had been done on the second visit to the home. Peoples rooms all had en suite accommodation. Some rooms were minimalist in style as dictated by the wishes of the people living in the home. One toilet bowl in an en suite was very stained and needs attention. On arrival the home had an unpleasant odour due to continence issues. The group manager stated that some carpets had been replaced and there were plans to replace further carpets on the first floor. Staff were observed cleaning and disinfecting the home. The laundry was extremely untidy during the first visit. A large number of shoes and other footwear were in a heap on the floor. An extractor fan was switched on to help reduce the heat in the room. This was also very dirty and needs cleaning. There was no soap or paper towels in the laundry, indicating that staff do not wash their hands in the sink provided. This could be an infection control risk when dealing with soiled laundry. Protective equipment such as gloves were provided. Colour coded mops and buckets were being used with guidance for staff. Evidence: Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Peoples needs are met by a competent staff team, who have access to a satisfactory training programme that provides staff with knowledge about the diverse needs of people living at the home. Systems for obtaining information required by us when recruiting new staff may place people at risk of harm or abuse. Evidence: The home does not have any vacancies for staff. A new member of staff had started working in the home the week of the inspection and they were observed shadowing a senior team member working through their induction programme. Other staff confirmed that during their induction they completed training in MORE, mandatory training and the Learning Disability Qualification. Staff spoken with had a good understanding of the needs of the people they support and said that they had been provided with specialist training in areas such as Autism, Epilepsy and Mental Health. Additional information about peoples complex needs were provided on their files. A National Vocational Qualifications (NVQ)programme was in place in the home and one staff member said they had been registered to start their award. The DataSet indicated that 36 of staff have a NVQ Award at Level 2 or over and that another 36 of staff were working towards their awards. Recruitment and selection files were examined for five members of staff who had started working in the home between December 2007 and October 2008. A front sheet on each file indicated when documents had been received. All records except for one were satisfactory ensuring that all documents had been received prior to appointment. Gaps in employment history were explored and the reasons for this recorded on their application form. Where people had worked previously in care, the reason for leaving had been received from former employers. One staff file had gaps in employment history. Criminal Records Bureau (CRB) checks were satisfactory. Where staff had been employed without a CRB check a povafirst check had been completed and the relevant risk assessment was in place. Staff confirmed that they shadowed staff and Evidence: did not take people into the community until their CRB check had been returned. Proof of identity and a current photograph were in place. Robust training systems were in place from induction through to the NVQ programme and professional development of managers. A training matrix was in place and there was evidence that staff had been put onto training courses for refresher training. Copies of certificates were kept on each staff members file. Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Effective quality assurance systems are in place involving people. Systems are in place to maintain and monitor the health, safety and welfare of people. Evidence: The registered manager had considerable experience supporting people with a learning difficulty and had the Registered Managers Award and NVQ in Care at Level 4. During the inspection she was attending training with the Institute of Applied Behavioural Analysis. She was receiving regular supervision and support from the group manager. There were a number of small inconsistencies in care plans, staff records and health and safety records. Most of these had been complied with at the time of the second visit to the home. She also gave a summary of what had been put in place to comply with other shortfalls. The quality assurance review of the home had been conducted in August 2008 and reflected significant improvements in the service being provided. Feedback was obtained from people living in the home, their relatives and care managers. A copy of these responses was inspected and a report was to be produced with an action plan for the forthcoming year. Comments included, excellent, positive that a company puts so much emphasis on training their staff, and the manager always offers her support and for us to talk to her, especially after incidents. One person commented they would like more drivers. The group manager regularly visits the home to conduct Regulation 26 visits and copies of these reports were examined. The registered manager was given an action plan at the end of each visit and there was evidence that she had been putting this in place. Systems were in place to monitor health and safety within the home. There was Evidence: evidence that Regulation 26 visits were also checking on these and reminding the manager when checks were not being completed routinely. Good food hygiene practices were observed to be in place. The home had the Better Food Safer Business Guide. Fire equipment checks were being completed along with water temperatures and hot food temperatures. The fire procedure indicated that people could be left in their rooms to wait for the fire brigade. This is contrary to advice from the Fire Service and was amended in line with individual risk assessments in the home. Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 1 6 The Statement of Purpose 30/12/2008 and Service User Guide must be reveiwed on a regular basis. This is to provide people wishing to move into the home with up to date information about the service they will receive. 2 14 16 People must be able to engage in social and community activities by providing appropriate transport systems. 23/11/2008 This is so that people are able to access their local community and participate in their programme of activities on a regular basis. 3 20 13 24/11/2008 Where a compliance aid is used to provide medication to people on social leave, procedures, risk assessments and labelling of the compliance aid must be in place. This is to safeguard people from possible harm due to medication error. 4 30 23 Odours must be minimised and the laundry/en suite toilets must be kept clean and tidy. 24/11/2008 This is to minimise risks of infection. 5 34 19 Staff must not be employed 24/11/2008 in the home until any gaps in employment history are investigated. This is to safeguard people living in the home from possible abuse or harm. 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 Amendments to care plans and other related documentation should be made to reflect current information about the person. Consider reviewing documentation with placing authorities concerning restrictions to liberty or freedom in line with the Deprivation of Liberty safeguards. Care plans should identify the gender of staff providing personal care to people. Healthcare records should be completed to provide evidence that people are having access to regular appointments with dentists and other healthcare professionals. The complaints procedure should be amended to include 2 7 3 4 18 19 5 22 current contact details about the Commission. 6 7 24 42 Fire doors should be checked regularly to ensure that they close securely and are fully operational. The fire procedure should be reviewed in line with individual risk assessments. Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone : 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web:www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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