Inspection on 05/01/09 for Blossom Community Care

This inspection was carried out on 5th January 2009.

CSCI found this care home to be providing an Adequate 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

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: Blossom Community Care 48 Kelvin Avenue London N13 4TG     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: Margaret Flaws     Date: 0 5 0 1 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. the things that people have said are important to them: They reflect 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 32 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: Blossom Community Care 48 Kelvin Avenue London N13 4TG 02088880323 Telephone number: Fax number: Email address: Provider web address: blossomcare@hotmail.co.uk Name of registered provider(s): Type of registration: Number of places registered: John McGown,Mr Luke Fantham care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: Date of last inspection Brief description of the care home The home was established to provide residential care to young men with enduing mental health needs. It is a three bedroomed house in a residential street in Palmers Green, North London and is a short distance from Wood Green. The home is well served by local transport, shops, parks and community facilities. The home is an ordinary small terraced house and has been refurbished to a good standard. There are two bedrooms on the first floor and one on the ground floor. All rooms have an ensuite facility consisting of a toilet and a washbasin. The rooms are furnished to a good standard. The bathroom is on the first floor and there is an additional toilet downstairs off the lounge. There is an ordinary galley kitchen and the fridge, washing machine and dryer are under the stairs. The small lounge/dining is pleasantly furnished. There is an ordinary garden and patio area at the the back of the house. The fees for the home are from £650-750 pw. 3 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unnannounced inspection was took place over one day. One of the Registered Providers, Luke Fantham, and the Acting Manager, Sandra Hancock, were present throughout and assisted with the inspection. This inspection consisted of discussions with residents, interviews with the Registered Provider, the Acting Manager and the care staff member on duty. We toured the premises, observed interactions between staff and residents and their routines. We inspected care, staff and general records in the home. The home provided CSCI with a basic Annual Quality Assurance Assessment (AQAA),which contributed information to this inspection. Care Homes for Adults (18-65 years) Page 5 of 32 Care Homes for Adults (18-65 years) Page 6 of 32 What the care home does well: What has improved since the last inspection? What they could do better: The Statement of Purpose needs updating. The home needs clear written guidelines for referral, assessment and admission and ensure that a comprehensive assessment is carried out by people trained to do so before anyone is admitted to the home. The home must have a copy of the local authoritys safeguarding policy and procedure readily available. The home must have an infection control policy and procedure. Pre-recruitment checks should comply with requirements set out in Schedule 2 of the Care Standards Act 2000. The home must develop and implement its own staff training programme covering all mandatory areas of training on a regular basis and in other areas where the residents would benefit from staff having a better understanding of their needs. The home should commence a formal training programme for staff and managers in mental health issues. The home must ensure that staff achieve NVQ qualifications. Staff should have training on diabetes. Regulation Thirty Seven reports covering circumstances detailed must be sent to CSCI as necessary. The Registered Providers must inform CSCI in writing of any changes to the management arrangements and tell how the home is being managed. The home must recruit and appoint a Registered Manager as soon as possible. Care Homes for Adults (18-65 years) Page 7 of 32 The Registered Providers must familiarise themselves with all the National Minumum Standards and Regulations and the responsibilities these outline. The service should build its mental health expertise and capacity through employing or contracting appropriately skilled professionals who can help them with this task. The home must create and store its records in the home and the homes office systems must function to support this. The home is required to have a fire safety risk assessment. Fire drills must be undertaken and documented four times per year, including one drill at night. Recommendations It is recommended that the home does not accept any residents with forensic mental health histories at this time. It is recommended that the home consider creating a covered space for outdoor smoking. 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. Care Homes for Adults (18-65 years) Page 8 of 32 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 32 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. New residents would benefit from having clear referral and assessment guidelines in place and better information available to them in the homes Statement of Purpose. Evidence: This is the first inspection for this service, which began to operate with its first new referral and admission in April 2008. At the time of this inspection, there were three people living in the home. Two of these residents came to live there as a result of emergency admissions from another care home where the residents had to leave. We checked the files for all the people living in the home. All the residents are young men with enduring mental health needs, in line with the stated purpose of the home. The first person to be admitted had complete information on file, including assessment information. The other two people had some assessment information on file but the Acting Manager told us that this was not provided at the time of their emergency admissions and took some time to obtain from the local placing authority. The home Care Homes for Adults (18-65 years) Page 10 of 32 Evidence: completed its own assessment of these new residents but told us that it was difficult to get ascertain important background because of the lack of information provided at the time of their admissions. The Acting Manager told us that the placing authority visited after six weeks of these two residents coming to live in the home. Both residents said that they preferred Blossom to the home they had previously lived in. The other resident had been admitted after an extended hospital stay. He had not lived in residential care before but said that he had had a positive experience living in the home. The Acting Manager and Provider also told us that they had had two other residents placed in the home where the placements had not been suitable and that these people had moved on. Because of issues outlined to the Registered Providers when the home was first registered with CSCI - that the Registered Providers have no experience of the care industry; that this is a new home providing mental health care and needed to build its capacity to do so - and because the home is currently without a Registered Manager, it is vitally important that there be clear guidelines in place for referral, assessment and admission to the home. A requirement is given that the home review its procedures, write clear guidelines for referral, assessment and admission and ensure that full assessments are carried out by people trained to do so before any admission. Further, it is recommended that the home does not accept any residents with forensic mental health histories at this time. The home has a Statement of Purpose, which we saw. It covers some of the information needed but needs updating to reflect everything required in Schedule One of the Care Standards Act. A requirement is given. Care Homes for Adults (18-65 years) Page 11 of 32 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 living in the home have their care planned according to their needs and wishes, and they are actively involved in identifying and planning for their needs. They are supported to make their own decisions and choices and work towards degrees of independance. Risks to their wellbeing are assessed and managed to protect their interests. Evidence: We saw the care files and plans for the three people living in the home. There were basic care plans for each of them, which had been reviewed by the staff at the home. The Acting Manager said that she had been reviewing the care plan format and will be making improvements to comprehensively reflect a range of peoples physical, social, emotional and mental health needs and their individual wishes, goals and life stories. She and the another staff member on duty were able to give a good account of the Care Homes for Adults (18-65 years) Page 12 of 32 Evidence: way the home worked in a person centred way to consider, plan and meet the individual needs and wishes of each resident. The daily notes also gave a reasonable account of how the home worked with each person. Some risks were assessed and documented for each person and the residents will benefit as it develops these further. We observed good communication throughout the day between the residents and the staff. The residents discussed their needs with staff and staff demonstrated a good understanding how to support them. There is a good system in place for supporting people with their finances. The Acting Manager told us that the residents manage their own finances and the staff support them with budgeting and managing their money. Each person has a safe in their room. Care Homes for Adults (18-65 years) Page 13 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents enjoy a good range of activities that meet their needs and preferences. Contact with relatives and friends is supported in line with their wishes. Their rights and responsibilties are respected and promoted within their daily lives and they enjoy balanced and varied meals that meet their needs and preferences. Evidence: We spoke to the residents who were all at home on the day of the inspection. One resident said that he goes to the local Chinese Day Centre three times per week and enjoys it. He said he also likes playing and listening to music in his room. The other two residents do not attend day centre at the moment.The residents said they choose how they spent their time and the activities they participate in. This includes the activities detailed above and going shopping, going to the library, sports centre, to the cinema and other community leisure activities. The Registered Provider said that Care Homes for Adults (18-65 years) Page 14 of 32 Evidence: everyone in the home, staff and residents, were going to do a computer course together. The Registered Manager also described how she informally supports one resident to build his English language skills in ways that he enjoyed. Two residents visit family regularly, who live nearby. One resident, who comes from China, keeps in regular touch with his family by phone. Residents said that the home supports them to maintain contact with their families. The home has a stated aim of rehabilitation and increasing peoples independance. The residents participate to different degrees in the running of the home. For example, the residents said that they participate in planning the menus and help with the shopping and meal preparation.One resident said that he cooks simple things for himself; another resident does some meal preparation and another helps to organise the cooking. The two residents who have moved from another home said that they preferred living in this home. The other resident said that although he had not lived in a care home before, Blossum had given him good support and that he looked forward to moving into independent living. We saw the menus. The four week cycle included normal home cooked meals but staff said that it can vary according to the residents choices on a daily basis. The home had a reasonable stock of fresh fruit and vegetables and other basic ingredients and snacks. Menus included the cultural choices of the residents. Care Homes for Adults (18-65 years) Page 15 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do not need personal care support. Their physical and mental health needs are assessed and met, with specialist support as required. They are also protected by the homes new medication policies and procedures. Evidence: The residents do not need any support with personal care, other than occasional prompting and verbal support.We saw the files for all the residents. All had had regular physical health checks and the Acting Manager described how she has advocated with health professionals on the residents behalf to get them necessary diagnoses and health support, for example, for a resident with diabetes and cataracts. We discussed how the home was currently supporting this residents diabetes management. Staff have been working with him to monitor his blood sugar levels and the home is currently trying to get specialist support for this resident to stabilise his diabetes. A requirement is made under the Staffing section of this report for the home to access diabetes training for staff to help them keep up to date with best practice and knowledge in this area. Care Homes for Adults (18-65 years) Page 16 of 32 Evidence: Peoples mental health needs are well supported by the involvement of community mental health teams and we saw evidence on file of how the home works with these teams on regular basis. The Acting Manager also described to us how she consults with professionals as and when required. She had a good understanding of the mental health needs of the residents and how to support them, while agreeing that further, specific mental health training would add to her knowledge and that of the team. The home has a medication policy and procedure which covers the storage, administration and safe handling of medications. It also has a section on the selfadministration and states that all residents who self-administer their medications will have a risk assessment to cover this. We discussed medication with the Acting Manager and she showed us the medication storage arrangements in a medication cupboard in the office, which was in good order. Controlled drugs are stored seperately in a locked cupboard. We checked the Medication Administration Records for two residents. There were no errrors or omissions on these records. Medication cupboard and fridge temperatures are checked and recorded daily, to ensure medications are stored at safe temperatures. Two residents self administer their medication and there are individual risk assessments for them. One person also administers their own diabetic medication and staff monitor when he checks his blood sugar levels. A requirement that staff have diabetes training is made under the Staffing section of this report. Care Homes for Adults (18-65 years) Page 17 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can express their views and concerns and know that these will be addressed appropriately by the home. They are also generally safeguarded from harm by the homes policies, procedures and staff understanding of how to put these into practice. Evidence: The home has an accessble complaints policy and procedure, which is displayed in the home. Residents we spoke to said that they knew what to do if they had any concerns and that they felt confident to raise issues as they arose. We saw the complaints records. No complaints had been recorded since the home started operating last year. The home also had a safeguarding adults policy and procedure but staff could not locate the local authoritys policy. A requirement is given that there is a copy of this document readily available. Care Homes for Adults (18-65 years) Page 18 of 32 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home that is well decorated and maintained to meet their needs. The home was clean and tidy throughout and residents said that they liked their physical surroundings. Evidence: We toured the building with the Registered Provider and the Acting Manager. The home has been refurbished to a good standard, with pleasant decoration and furnishing. While small, the communal facilities are adequate for the needs of three residents and the current residents said they liked the space. There is a small, comfortable lounge with TV (with freeview access), DVD and music system. The small galley kitchen was in good order, with a locked cupboard for dangerous substances (COSHH), adequate work surfaces and normal domestic food storage arrangements. Fridge and freezer temperatures are recorded daily. The fridge, washing machine and dryer are under the stairs next to the kitchen. This was discussed with the Registered Providers at registration and, while it was agreed that this wasnt an ideal location, an extractor fan and thermaboard panel were put in place and staff said that these arrangements were working safely. The bathroom is upstairs and there is a second toilet off the lounge on the ground Care Homes for Adults (18-65 years) Page 19 of 32 Evidence: floor. Two residents showed us their rooms. These were highly personalised and furnished to a good standard. One resident liked music and showed us his electric organ, guitar and music system. Residents have television in their rooms. The residents use the outside patio area for smoking and during the inspection and they were often outside having a cigarette. It was a very cold day and it is recommended that the home consider building a covered space for outdoor smoking. The staff office on the first floor has a sofa bed which sleep in staff use. This appears cramped and just adequate and may need to be reviewed. The home was clean and hygienic but needs an infection control policy and procedure. A requirement is given. Care Homes for Adults (18-65 years) Page 20 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are generally protected by the staff recruitment, training and support policies and procedures, although there is a need for improvements. Evidence: On the day of the inspection, there was one staff member and the Acting Manager on shift. We saw the staff rota. The Registered Provider and the Acting Manager said that the staffing level was adequate at present (two staff on duty during the day and one at night, with as and when staff bought in as needed) but this appears to be a minumum staffing level and it is recommended that the home keep this under review to ensure that there are always sufficient staff to meet the needs of the residents. The home has a satisfactory staff recruitment process. We checked five staff files. As the service is relatively new, most staff were new. Staff had had pre-employment checks, including full Criminal Records Bureau checks, two written references obtained and photographic identification supplied. However, some areas of pre-employment checking did not comply with requirements set out in Schedule 2 of the Care Standards Act 2000 and the Registered Person was not familar with these prerequisties. For example, one person did not have a completed application form; another application form did not give a full account of the persons employment Care Homes for Adults (18-65 years) Page 21 of 32 Evidence: history, including gaps in employment; another persons right to work in this country was not fully documented and staff did not have pre-employment health checks documented. Most staff have come to work at Blossom from other care homes and had had a range of training prior to starting work. These included areas of mandatory training, including first aid, medication, safeguarding adults, fire and health and safety, inspection control, food hygiene and challenging behaviour. However, the home now needs to develop and implement its own staff training programme covering all mandatory areas of training on a regular basis. They should also commence formal training for staff in mental health and ensure that staff are supported to achieve NVQ qualifications. Staff should also have training on diabetes and in any other areas where the residents would benefit from staff having a better understanding of their needs (requirements given). Staff members on duty described the training that they have received and were able to tell us about the supervision provided (at the moment, by the Acting Manager). Staff meetings are held regularly. Care Homes for Adults (18-65 years) Page 22 of 32 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. Residents are only adequately protected by the homes management arrangements and systems and health and safety arrangements. Residents are consulted and their views are taken seriously. Evidence: During registration with CSCI, the Registration Inspector stated to the Registered Providers that, because of their lack of background in the care industry, they would need the support of a good manager who knows the business of caring for people with mental health problems. The Registered Manager for the service,who had an NHS background, left in the first months of operation in 2008. The Registered Providers did not inform CSCI that the Registered Manager had left at this time and do not have a good understanding of reporting under the Regulation Thirty Seven. The Registered Provider we spoke to was not fully aware of the these responsibilities nor was he familiar with the National Minimum Standards. A requirement is given that Regulation Thirty Seven reports be sent to CSCI covering circumstances as detailed in Care Homes for Adults (18-65 years) Page 23 of 32 Evidence: the Care Standards Act 2000. Additionally, the Registered Providers must inform CSCI in writing of any changes to the management arrangements and tell us how the home is being managed. They must become familiar with all the National Minumum Standards and Regulations and the responsibilities that these entail. A further requirement is given. The home is currently without a Registered Manager. An Acting Manager with experience as a Deputy Manager in other care homes, Sandra Hancock, has been covering the management of the home. Feedback from the staff and the residents indicated that her management has been positive, proactive and supportive. She has completed an NVQ4 in Care, has almost completed a Registered Managers Award and has some experience in the care of older people with enduring mental health needs. We discussed the management arrangements with the Registered Provider. This inspection demonstrated that there is a need in the home for a Registered Manager with a solid background in care and with management skills. There is also a need for the home to access good mental health expertise in building the capacity of the service. A requirement is given that the home recruit and appoint a Registered Manager as soon as possible. A further requirement is given that the service builds its mental health expertise and capacity through employing or contracting appropriately skilled professionals who can help with this task. Management staff must also build their mental health skills and knowledge base and undertake ongoing training in this area. In the office, the home has a computer but it was not fully functional at the time of the inspection. The printer was not working and it was not possible to access documents and files relevant to the care needs of the residents and the running of the home. A requirement is given that the home produces and stores these records in the home and that the homes office systems function to support this. In the Annual Quality Assurance Assessment provided to CSCI, the dates for health and safety certificates given incorrectly. We discussed this with the Registered Provider and he said that some certificates were with the other Registered Provider who was out of the country and he will follow up. Within three days of the inspection, he was able to provide the correct certificates, including up to date electrical and portable electrical equipment certificates, gas safety certificate and documentation of recent fire safety checks. The home did not have a fire safety risk assessment at the time of the inspection and a requirement is given to obtain one. A further requirement is given to undertake and document fire drills four times per year. Care Homes for Adults (18-65 years) Page 24 of 32 Care Homes for Adults (18-65 years) Page 25 of 32 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 26 of 32 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 1 4 The Registered Persons 31/03/2009 must ensure that the homes Statement of Purpose includes all the areas required in needs updating to reflect everything required in Schedule One of the Care Standards Act 2000. Prospective residents must have full information about the home before they move in. 2 2 14 The Registered Persons must ensure that there are clear written guidelines for referral, assessment and admission and ensure that a comprehensive assessment is carried out by people trained to do so before anyone is admitted to the home. 31/03/2009 Care Homes for Adults (18-65 years) Page 27 of 32 The home must have clear referral, assessment and admission guidelines in place. 3 22 12 The Registered Persons must ensure that they have a copy of the local authoritys safeguarding policy and procedure readily available Staff need to be clear about what the host local authority expects them to do and who to contact if they have a safeguarding concern. 4 30 30 The Registered Persons must ensure that the home has an infection control policy and procedure. Infection control in the home must guided by best practice 5 32 18 The Registered Persons must ensure that staff achieve NVQ qualifications. Staff need to achieve minimum qualifications for their work 6 34 18 The Registered Persons must ensure that all prerecruitment checks set out in Schedule 2 of the Care Standards Act 2000 are carried prior to new staff starting work. Staff must be safely recruited 31/03/2009 30/06/2009 30/04/2009 31/03/2009 Care Homes for Adults (18-65 years) Page 28 of 32 7 35 18 The Registered Persons must ensure that staff have training on diabetes. Staff should be trained to meet residents needs 30/04/2009 8 35 18 The Registered Persons 30/06/2009 must commence a formal training programme for staff and managers in mental health issues. Staff should be trained in the homes specialist area 9 35 18 The Registered Persons must ensure develop and implement the homes own staff training programme covering all mandatory areas of training on a regular basis and in other areas where the residents would benefit from staff having a better understanding of their needs. Staff must be properly trained 30/06/2009 10 37 8 The Registered Persons 30/04/2009 should the mental health expertise and capacity of the service through employing or contracting appropriately skilled professionals who can help them with this task. The home must build expertise in its specialism. 11 37 7 The Registered Persons must familiarise themselves with all the National Minumum Standards and 31/03/2009 Care Homes for Adults (18-65 years) Page 29 of 32 Regulations and the responsibilities these outline. The providers must understand their responsibilities as outlined in the Care Standards Act 2000. 12 37 8 The Registered Persons must recruit and appoint a Registered Manager as soon as possible. The home must be properly managed 13 37 8 The Registered Persons must inform CSCI in writing of any changes to the management arrangements and tell how the home is being managed. CSCI must know how the home is managed 14 37 37 The Registered Persons must send Regulation Thirty Seven reports covering circumstances detailed under Regulation Thirty Seven of the Care Standard Act to CSCI as necessary. Reporting requirements must be met 15 41 17 The Registered Persons 30/04/2009 must resource the home to create and store its records in the home and the homes office systems must function to support this. 31/03/2009 31/03/2009 31/03/2009 Care Homes for Adults (18-65 years) Page 30 of 32 The home must have appropriate recording and management systems 16 42 12 The Registered Persons must ensure that fire drills are undertaken and documented four times per year, including one drill at night. Health and safety must be protected. 17 42 12 The Registered Persons must ensure that the home has a fire safety risk assessment. Health and safety must be protected 31/03/2009 30/04/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 2 24 It is recommended that the home does not accept any residents with forensic mental health histories at this time. It is recommended that the home consider creating a covered space for outdoor smoking. Care Homes for Adults (18-65 years) Page 31 of 32 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 © (2009) Commission for Social Care Inspection (CSCI). 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