Inspection on 15/09/08 for Carisbrooke

This inspection was carried out on 15th September 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carisbrooke 20/09/07

Carisbrooke 16/08/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Carisbrooke 35 Welholme Road Grimsby North East Lincs DN32 0DR     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: Kate Emmerson     Date: 1 5 0 9 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. 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 30 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 30 Information about the care home Name of care home: Address: Carisbrooke 35 Welholme Road Grimsby North East Lincs DN32 0DR 01472354434 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Diamond Care (2000) Limited care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home Carisbrooke is a residential care home situated close to the centre of Grimsby overlooking Peoples Park. The property is a large Victorian house with the accommodation set over three levels. Fees per week are £350.02. 12 Over 65 12 Care Homes for Adults (18-65 years) Page 4 of 30 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 inspection was unannounced and was conducted over one day in September 2008. The last inspection of this service was completed on 20 September 2007. The manager had completed a quality assessment form for the Commission prior to the inspection, which gave information on how the home was managed. Prior to the inspection the Commission had sent questionnaires to staff and people who lived in the home to enable them to give their views. Five staff surveys were received and four surveys were received from people who lived in the home. All gave very positive comments about the home and the management. During the visit to the home we spoke to the staff on duty and the manager. The Care Homes for Adults (18-65 years) Page 5 of 30 people who lived in the home were spoken with to establish their views on the care they received. The interaction between staff and residents was observed throughout the inspection. A selection of records relating to the care provided, staff recruitment and training and health and safety in the home were examined. A tour of the building and garden was also completed. Following the inspection the manager provided additional information which has been included in this report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? They have made sure that they get two written references for all staff before they start to work in the home to enable them to check staff are suitable. They have made sure that staff receive regular supervision. This was to make sure that staff feel supported and for the manager to ensure that they are competent in their work. They have reviewed the managers hours to ensure that he has sufficient time to carry out management tasks. They had provided staff with training in moving and handling but should make sure that they plan for this to be completed every year to ensure safe practice. Care Homes for Adults (18-65 years) Page 7 of 30 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.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 30 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 30 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. Peoples needs were assessed before they moved into the home and they were provided with detailed information about the services provided. Evidence: There had been no new admissions to the home since the last inspection. Assessments held on file were examined and these detailed peoples needs and the way they liked to live their lives. They had been completed together with the person using the service and, where appropriate, families and specialist teams such as the Community Team for Learning Disabilities. The home had reviewed and further developed the assessment format since the last inspection to ensure that comprehensive information is obtained during the assessment process. The information provided to people about the home and the services provided had been reviewed and updated since the last inspection and the information provided in the AQAA (Annual Quality Assurance Assessment) stated that these documents were Care Homes for Adults (18-65 years) Page 10 of 30 Evidence: available in audio format and in other languages/braille/large print on request. People were able to visit the home prior to admission. One person said in a survey I came for dinner and looked at the bedroom. Care Homes for Adults (18-65 years) Page 11 of 30 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. All the people who lived in the home had a detailed care plan which set out their needs and preferences. People were consulted on all aspects of their lives and were supported to be as independent as possible. Evidence: A selection of care plans was examined. These had been developed from the information collected at assessment and with the involvement of people living in the home or their representative. The format for care planning had been improved and the majority of the care plans had been transferred onto this. There was a wealth of information recorded which detailed needs and how these should be met. Although staff and management stated care plans were evaluated regularly there were no records of the evaluation however there was evidence the care plans had been updated as needs changed. Care Homes for Adults (18-65 years) Page 12 of 30 Evidence: The care plans included risk assessments where appropriate. There was improved care planning to manage challenging behaviour and a system of monitoring and recording challenging behaviour had been put in place. This was not fully embedded in practice as there were some instances of challenging behaviour that had been recorded but not included in the homes new monitoring records Staff showed good knowledge of individuals care needs and previous history. They had a clear understanding of individuals preferences, likes and dislikes and daily routines. They confirmed that they had up to date information about the people they were caring for. One said if there is any new information or changes with the people we support their individual care plans are updated as soon as possible and another said information is passed over at all times. We received surveys from some of the people living in the home and during the inspection we spoke to some of them. They said that they were well cared for and they were able to make decisions about their daily routine. Comments included I do my paperwork and look at my books and I am happy and looked after well. Staff constantly maintained individuals state of involvement with one another by including them in conversations, seeking their opinions and asking them questions about their day etc. Staff provided information on community life and offered choices, which were often taken up. One person had a voluntary job doing outdoor work and attended the local college and at others attended day services where they interact with friends and acquaintances or engage in activities. One person loved gardening and helped the manager attend to the homes garden. The manager stated that all the people in the home were supported to some degree with their finances. The manager stated that he is appointee for nine people. Individual records of financial transactions were maintained and a random selection of these records was examined. The records balanced with cash held and receipts were maintained for purchases. The records were audited annually by the providers. Care Homes for Adults (18-65 years) Page 13 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoyed satisfying lifestyles of their choosing, with support from staff where necessary. Evidence: People spoken to were very satisfied with the lifestyles they lead. One said I go to the day centre and in the evenings play bingo and I visit my mother regularly, another said I help with gardening, go walking in the park, watch football, visit my brother and work in the community chest. Other people attend day care services at different establishments belonging to the social services or voluntary groups. They use arranged transport and have set days to attend. Two staff commented in survey that they thought the service could improve by Care Homes for Adults (18-65 years) Page 14 of 30 Evidence: offering more activities outside the home. There was evidence that staff encouraged people to maintain contact with their family. One person described in their survey how they went to stay with family at the weekend. People were supported to take part in community activities appropriate to their mobility. Usually they went out in twos or threes to the pub, to go shopping, or to visit the cinema. The manager had requested extra funding to support increased staff input for two of the people living in the home due them requiring one to one attention during activities. This had been obtained and was planned in advance. One person went out with their key worker for lunch during the inspection. People could have a key to their room if they requested it and if they are risk assessed for safety and security, but only one held a key. People were observed asking for a hot or cold drink at all times of the day, which were provided. They discussed what they liked to eat on a daily basis, they had chosen spaghetti bolognese on the day of the inspection. Staff explained that people have made their likes and dislikes known to them over the years and when preparing meals know what they will or will not try. There were no set menus but records of food served were available. This showed a variety of different meals was provided and indicated that there was flexibility to meet individuals preferences. For example a main meal was provided at lunchtime to those not at work or at day centres but one person preferred their hot meal at teatime so this was provided. Tea was a lighter meal. Staff were observed assisting people with their meals as required. Aids were provided to enable people to be more independent. People spoken to did not make any adverse comments about food provision, comments made were the the food is good, and I like my dinners. Care Homes for Adults (18-65 years) Page 15 of 30 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. People enjoyed a good level of support with their health care and personal care, and with administration of their medicines. Evidence: The manager and staff provided detailed information about individuals health needs and how they were met. Since the last inspection health action plans had been completed by the community learning disability team and these were held in each care file. Records were completed when a person had seen a health professional and these indicated that staff interventions to arrange these visits were appropriate and timely. There had also been improvements in care plans for people who had problems eating and drinking. Care plans for one person who required full support with their meals included a nutritional risk assessment and their weight had been monitored regularly. The home had an up to date policy and procedure for the safe handling of medication. Care Homes for Adults (18-65 years) Page 16 of 30 Evidence: Staff training records showed staff were trained to administer drugs. Records seen on medication receipt and administration were well maintained. Records to show what medication had been returned to the pharmacy were now available. One person was prescribed a medication on an as required basis to manage a behavioural problem. A management plan had been developed since the last inspection to describe to carers when this medication should be given to ensure a consistent approach. There were no people living in the home that self-medicated and those spoken to were of the opinion that medicines were best held locked away and did not want the responsibility of looking after theirs. Understanding and competence varied amongst people living in the home, but they were satisfied with the way their personal and health care needs were met. Care Homes for Adults (18-65 years) Page 17 of 30 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 have access to complaint procedures within the home and are confident their concerns will be dealt with appropriately. There were procedures to protect people from abuse. Evidence: People living in the home could not remember ever making a complaint. When asked if they knew what to do to if they were unhappy with the care at the home comments included I would go to a member of staff, I would go to my key worker or staff and one said they would go to staff or family. None of the people spoken with had any complaints about the service. One said I am happy and looked after well. There was open communication observed between staff and people living in the home and residents were clearly comfortable expressing themselves and offering their opinions. Staff took their time to understand people where they had communication difficulties. There was a complaint policy and procedure available in the home and within the statement of purpose, and staff understood the action they must take if anyone does have a complaint to make. There had been no complaints made to the Commission and none recorded in the home in the last twelve months. Two minor concerns (message taking and laundry issues) had been recorded since the last inspection. The manager was advised that the current format for recording Care Homes for Adults (18-65 years) Page 18 of 30 Evidence: concerns did not protect confidentiality and should be reviewed. There were policies and procedures in place to protect people from abuse or neglect. It was evident from staff responses and training records that staff had received training in this area although annual refresher training was due. The manager had also completed this training as well as training on equality and diversity. Care Homes for Adults (18-65 years) Page 19 of 30 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. People enjoyed a good level of cleanliness and hygiene within the home and the fabric of the building was reasonably well maintained although some areas required updating. The garden was not safe for all the people living in the home to access. Evidence: A tour of the building and garden was conducted. The manager and one of the people living in the home had continued working to improve the garden over the summer and had cleared all the overgrown areas. Further work was required to make full use of the garden and to ensure that it was a safe environment for all the people living in the home. (see the section relating to conduct and management of the home) Bedrooms were personalised and comfortable and the home was generally clean and tidy. Although four of the eight rooms were doubles, most were fitted with good partitioning dividers to offer separate areas for each person. One bedroom was not fitted with a partition but portable screening had been provided since the last inspection. The bathrooms and shower room were run down and need of updating and Care Homes for Adults (18-65 years) Page 20 of 30 Evidence: refurbishment to improve the environment for people living in the home and aid cleaning. Written information has been received from the manager to advise us that work was to commence on the bathroom on the third floor. Wheelchair access was available to the front and the house had an internal ramp to the rear. The laundry was domestic in style and equipment meets the Water Supply (Water Fittings) Regulations 1999. The kitchen had been refitted and the manager stated that the home had achieved a four star rating from the environmental health officer. At the time of the inspection they were waiting for a new cooker to be fitted, written confirmation has been received by the Commission that this work has been completed. Staff had completed infection control training and practice in maintaining cleanliness and preventing spread of infection was good. Training records, copy certificates and observation evidenced this. Personal protective equipment was seen in use and staff followed good food hygiene procedures and policies. Care Homes for Adults (18-65 years) Page 21 of 30 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. The people living in the home benefited from a stable staff group who had received training and regular supervision in their role. There was no evidence dependency of individuals was used in determining staffing levels. There were some deficiencies in staff recruitment, which means that checks on the suitability of staff to work in the home were not always complete. Evidence: The home had a small but stable staff group with very low turnover which was beneficial for the people who lived in the home as staff had developed in-depth knowledge of people living in the home and how care was to be delivered to meet their needs. The manager stated that the home provided three hundred and thirty care hours per week. A further forty three hours per week had been implemented to support two of the individuals on a one to one basis. Staff commented in surveys that it would be better to have enough staff to be able to cover shifts when staff were on annual leave or sickness as staff have to do double shifts to provide cover. Staff also commented Care Homes for Adults (18-65 years) Page 22 of 30 Evidence: that the staff work well as a team and found the management approachable. The manager stated that he works for sixteen hours supernumerary and the rest of his hours as the second care staff on duty. Care staff were also responsible for cleaning tasks and cooking meals during their care shifts. The calculations for staff hours should be determined using the Residential Forum Guidelines applicable to the people accommodated. This calculates the staffing hours required in relation to individuals dependency levels and should be checked regularly to ensure staffing levels remain appropriate. The manager was not able to provide evidence that staffing levels were being determined using this tool and was requested to provide evidence of workings to the Commission. Three of the most recently recruited staff files were checked. The files contained most of the necessary checks to ensure that staff were suitable to work in the home. However in one case there was no evidence that a check of Protection of Vulnerable Adults (POVA) list had been checked prior to employment. The home should have applied for a POVA 1st check. People who lived in the home were involved in the recruitment and selection of new staff. They were present during interview and their comments about the staff were taken into consideration and recorded on interview records. The home was committed to supporting staff to gain qualifications in care. The evidence in pre-inspection questionnaire, staff files and discussion with the manager and staff showed there were six of the nine staff with the necessary qualifications at NVQ level 2. Three of these staff had also gained NVQ 3 and the manager had achieved NVQ 4. The manager had developed a detailed overview of the training required by individuals and a training plan to address shortfalls. The staff had completed most elements of the mandatory training requirements. Staff were due to completed annual refreshers in POVA training. Staff had completed moving and handling training had been provided but certificates stated that this did not require refresher training for three years, due to this being a high risk area it was recommended that annual refresher training is provided. The was some evidence that training to meet the specific needs of people accommodated had been provided, but this could be expanded to include, for example, management of challenging behaviour. There was evidence from staff files, surveys and discussions with staff that the standard of six supervision sessions in a year was on course for being achieved for Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: most staff. The manager stated that he supervises the senior staff and completes appraisals and senior staff complete supervision for the carers. The manager and the senior staff had received training in supervision and appraisals since the last inspection. Care Homes for Adults (18-65 years) Page 24 of 30 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. People benefit from having a manager that is qualified and registered and that maintains consistency within the service. They have use of a quality assurance system, but what provides them with a more effective means of inclusion is the culture within the home. There were some deficiencies in the management and monitoring of health and safety, which could have put peoples health, safety and welfare at risk. The manager addressed immediate areas of concern following the inspection. Evidence: The manager Dean Smith has been in post for two years. He is qualified with NVQ level 4 Registered Managers Award, and experienced at having managed and supervised staff for more than two years at another establishment within the company. He was observed to relate very well with staff and people living in the home on the day of the visit and they responded very well in return. Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: The manager stated he now had sixteen supernumerary hours per week in which to attend to management duties. The rest of his hours were spent as one of the two carers on shift. People and staff spoken to were aware of the ways in which people were consulted about their care and the support they receive: reviews and daily consultation being the main ones. People were confident they would be listened to and that any suggestions they have would be considered and adopted if possible. The manager stated that he was appointee for nine people living in the home. The records were well maintained and audited annually. A random selection of records relating to health and safety management was checked. On the day of the inspection the fire doors were not fitting/closing correctly this would suggest that although weekly fire alarm checks were completed the escape routes were not checked and staff were not ensuring fire procedures were followed at night. Written confirmation was received from the manager to confirm fire doors had been adjusted immediately following the inspection. The manager also confirmed that night time fire procedures had been reviewed and staffing levels adjusted accordingly. Staff had last received fire training in July 2007 but they had received regular fire drills. When the plumber accidentally activated the fire alarm the staff and residents alike acted swiftly and appropriately. It is recommended that as a minimum annual fire training is provided. The home had policies and procedures in place to support safe working practice. The majority of staff had received training in health and safety related areas such as food hygiene and infection control. Staff had completed moving and handling training had been provided but certificates stated that this did not require refresher training for three years, due to this being a high risk area it was recommended that annual refresher training is provided. (See outcome area relating to staffing) Records were maintained for any accident within the home. Care Homes for Adults (18-65 years) Page 26 of 30 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 27 of 30 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 34 19 A PoVA 1st check must be obtained prior to employment of staff. To make sure that the person is fit to work in the home. 02/03/2009 2 42 4 Regular checks of all systems and procedures relating to fire safety must be completed regularly. To minimise the risks of fire in the home and ensure that all related systems are in full working order. 02/03/2009 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 6 The care plans should be evaluated monthly and records of the evaluation maintained. This is to ensure that any changes to peoples needs are identified and care plans updated to reflect any changes. The garden area should be improved to provide a safe environment for all the people living in the home to access. Page 28 of 30 2 24 Care Homes for Adults (18-65 years) 3 24 The bathrooms and shower room should be updated and refurbished to improve the environment for people in the home and aid cleaning. The residential forum tool should be used to determine staffing levels in the home. To make sure that the dependency of the people accommodated is determined in calculating the number of care staff hours required. To expand the training programme in relation to peoples specific care needs. To provide annual refresher training in safeguarding vulnerable adults and moving and handling. To protect people working in the home and ensure safe working practice. All staff should complete annual refresher training in moving and handling and fire safety to ensure peoples health and safety. 4 33 5 6 35 35 7 42 Care Homes for Adults (18-65 years) Page 29 of 30 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). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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