Inspection on 12/01/10 for Carr Bank House

This inspection was carried out on 12th January 2010.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carr Bank House 08/12/09

Carr Bank House 22/10/09

Carr Bank House 30/06/09

Carr Bank House 17/06/08

Carr Bank House 05/07/07

Carr Bank House 11/06/06

Carr Bank House 31/10/05

Carr Bank House 03/07/05

Carr Bank House 18/08/04

Carr Bank House 01/04/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Random inspection report Care homes for adults (18-65 years) Name: Address: Carr Bank House 9-11 Heywood Street Bury Lancs BL9 7EB zero star poor service 30/06/2009 The quality rating for this care home is: The rating was made on: 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 review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Grace Tarney Date: 1 2 0 1 2 0 1 0 Information about the care home Name of care home: Address: Carr Bank House 9-11 Heywood Street Bury Lancs BL9 7EB 01617977130 01617631747 jocarrbank@btconnect.com 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) : Mrs Pauline Jones care home 14 Number of places (if applicable): Under 65 Over 65 0 mental disorder, excluding learning disability or dementia Conditions of registration: 14 The home is registered for a maximum of 14 service users, in the category of Adults with Mental Disorder (MD) under 65 years of age. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection Brief description of the care home Carr Bank House is a privately owned care home for 14 adults with mental health needs. There has been no change in relation to the weekly fees. These are 365.00 pounds per week. However this may vary depending on the persons level of assessed need. The home is located in a residential area, close to Bury town centre, within easy reach of buses and trams, shops, cafes, and other local amenities. The house consists of 2 adjoining properties that have been adapted to form a large Care Homes for Adults (18-65 years) Page 2 of 22 2 2 1 0 2 0 0 9 Brief description of the care home house. There is a small garden at the front and a large enclosed garden at the side. There are 12 single rooms and one double. Three bedrooms also have en-suite facilities. There are 2 lounges, an activities room, and a dining room. Care Homes for Adults (18-65 years) Page 3 of 22 What we found: We (The Care Quality Commission) undertook a visit to the home to check if the requirements made from the last inspection of the 8/12/2009 had been complied with. 2 inspectors and 1 pharmacy inspector undertook the inspection visit. The pharmacy inspector was needed because of the serious concerns that were identified on the last inspection around the management of medicines. We spent 11 and 1/2 hours at the home to check if the following had been actioned as required: Requirement: Care plans must detail the health and social care needs of the residents. We asked for the same care plans that we had looked at on the last inspection to see if any improvements had been made. We were shown 2 care plans that were in the process of being rewritten. Whilst there had been some improvement in the information in 1 of them, it did not give enough information and detail to show how this persons needs were to be fully met. This resident had been prescribed food supplements to help gain weight. There was nothing in the care plan to show that these had been prescribed and how often they were to be given. A special diet had also been prescribed following his discharge from hospital but we saw no detail, either in the care plan or in the kitchen, of the sort of foods to be provided. The other care plan that had been rewritten was not dated and not signed. Care records need to be dated and signed so that they show an accurate and up to date record of the residents condition at any one time. 2 other care plans that we looked at had not been updated since the last inspection. We asked to see the care plan of one of the residents whom we identified on the last inspection as having some serious problems. The manager told us that she was updating this care plan. We then asked if we could see the previous care plan but were told by the manager that it was not in the home. We also, later on in the evening, asked the care assistant if there was yet a care plan in the home for this resident and were told that there was not. The requirement had not been complied with. Requirement: Staff must make sure that any risk to the health and safety of the residents is identified and action taken to reduce or stop any identified hazard. From inspection of the care records that we looked at and observation of practices within the home we saw that there were hazards that could cause a risk to the health and safety of the residents and people working in, or visiting the home. 2 of the files that we looked at identified that the residents had unpredictable behaviour but there were no risk assessments to reduce or manage the risks. 1 resident was at risk of self harm but despite a very recent incident occurring, no risk assessment was in place. Risk assessments were not in place to show if it was safe for a resident to go out alone. Residents were smoking throughout the home including their bedrooms but there were no risk assessments for this hazard. Some of the hot radiators that were very close to the residents beds were not guarded. During the last inspection the manager was required to do a risk assessment for these until guards could be fitted. This had not been done. We saw there was a risk asessment in a file that was initially completed on the 15/2/2008 and the date had been changed to the 15/12/2009 however no changes had been made on the assessment in the last 12 months. The requirement had not been complied with. Requirement: A more varied menu must be provided that is nutritious and offers choice. Care Homes for Adults (18-65 years) Page 4 of 22 Special diets must also be provided for. The food stocks were totally inadequate. We were so concerned about the lack of food within the home that we issued an immediate requirement document requiring the management to provide enough food by 7pm that evening so that the dietary needs of the residents could be met. We also took photographs to show the minimal food stocks that were available. The immediate requirement was met that evening. The menus remain unchanged. There is very little choice of menu. Cereal or toast remains on the menu for breakfast. No dessert is offered at lunch. We saw that 1 resident was eating beans on toast later than everybody else. This had been left in the oven to keep warm and had solidified. Food was not being stored correctly. 1 meal of chips and minute steak muffin had been plated up and put into the fridge whilst still hot. There was condensation on the cling film covering it. 3 of the residents needed special diets for medical reasons but we saw no evidence to show that they were being provided. The requirement had not been complied with. Requirement: Protective clothing must be worn when preparing and serving food. We saw the staff who were in the kitchen or preparing food wearing their everyday clothes. Staff continued to wear their own clothes with no protective clothing. We saw that throughout the day there was a steady stream of people entering the kitchen. The requirement was not complied with. Requirements: All medicines must be stored safely and securely. There must be an effective auditing process in place to ensure that managers are confident that medicines are being handled safely. Effective arrangements must be put in place at the home to ensure that all medication records regarding receipt, administration and disposal are completed accurately. There must be effective systems in place to ensure staff that handle medicines are trained in medicines handling and are competent to do so safely. Effective arrangements must be put in place at the home to ensure that all medication is administered to residents in exact accordance with the prescribers directions. During the inspection the specialist pharmacist inspector looked at how well medicines were handled to make sure that residents were being given their medicines properly. This was because at the previous inspection we found that the systems of medicines management were unsafe. Very few improvements had been made to make sure that medicines were managed safely. One member of staff was responsible for managing medication on the day of our visit and she made sure that she kept the key on her at all times. An order for a Controlled Drug Cupboard had been made since the last inspection, it had not yet arrived. It is a legal requirement to have one. The medicines containers in the storage baskets had been tidied up. The manager told us she had held staff meetings to talk about the importance of safe medicines handling. The storage arrangements for medication were unsafe. Currently prescribed medication Care Homes for Adults (18-65 years) Page 5 of 22 was stored in a locked wooden cupboard. Medication which was waiting to be collected for destruction had been placed in open top crates on the floor of the staff office which was locked by means of a key pad. All staff had access to the office and residents came into the office to take their medication. There was no medication fridge available to store medication which might need cold storage. During the inspection we found a bottle of liquid medication for epilepsy had been left in the kitchen. All residents and staff had access to the kitchen at all times. Records about medication administration were poor and did not always show exactly what medication had been given residents or the time it had been given. We looked at the Medication Administration Record sheets (MARs) for all residents from the previous month. There were gaps on every record where staff had failed to sign to show if they had given or omitted medication. We compared the medication in the home with the records and found that on some occasions medication had been signed for as given but was still in the container. Or medication was not in the container and records had not been signed to show it had been given. There were a number of alterations and crossings out on the MARs making it difficult to tell if medication had been given or not. There were also symbols used on the records such as F, S ,O and stars which were not explained making it difficult to tell if medication had been given or not. During the inspection we saw staff give medication at a different time than was on the MARs but made no record of this time difference. The records about receipt of medication that had come into the home were poor and did not show that all medication was accounted for. The records for most medicines were so poor that checks could not be made to find out if medication had been given as prescribed. There was a record of medication to be returned to the pharmacy but it was not accurate as some medication which was in the crates awaiting collection for destruction had not been recorded. We found that no changes had been made to the way medicines were ordered from the doctor. The staff in the home still did not see what medication had been ordered by the GP. Other records about medication were still poor. No information recorded in the care plan for staff to follow about how to give medicines which were prescribed as a variable dose or when medication was prescribed when required. Some residents were given their medicines to look after when they were away from the home, but little or no information was recorded to show that it was safe for them to do so. We found records to show that residents did not want to look after their own medicine, but they were still given it to look after. There were no records made of the medication which was given to residents to take out or records of any checks done to see if they had taken their important medication properly. We found that residents were not always given their medication as prescribed or at the time it was prescribed. At the last inspection concerns were expressed that one resident may not have been given their contraceptive pill properly. At this inspection we had similar concerns. This ladys health could be at risk if the pill is not taken regularly. We found that medication which had been discontinued had been given on three occasions after it had been stopped. Medication such as Epilim syrup, which should be given twice Care Homes for Adults (18-65 years) Page 6 of 22 daily, was not given at the times it was prescribed. On one of the MARs staff wrote that the 8 pm dose of medication was given at 1am the following day and 2 days later, the morning dose of medication was given just before midnight. When medication is not taken properly residents heath is placed at risk. We watched staff give medicines to some residents and we observed poor practice. Staff placed the medication into their own hands and gave it to the residents in their hands. This is unhygienic; a medication pot should be used to minimize risk. We asked the manager for the policies and procedures about medicines. We were given two policies about self medication but neither was being followed. There was a policy about homely remedies, to enable residents to be given medicines that could be brought over the counter such as Paracetamol. However there was no stock of this type of medication. Staff told us that they gave people their medication in envelopes and other unmarked containers to take out with them when they are away from home. This is very poor practice as medication should not be removed from the packaging it is dispensed in, to avoid getting it mixed up or people taking the wrong medication. The manager told us that she had not made any checks, audits, since the last inspection in December 2009 to find out if medication was being handled safely by the staff. She also told us that staff had not received any medication training nor had their ability to handle medication safely checked since the December inspection despite serious concerns that medication handling was unsafe. There was no evidence to show that some staff had ever had medication training. None of the requirements made after the last inspection had been met. Residents health remains at risk of harm due to unsafe systems of medicines management. Requirement: A complaints procedure must be in place and a copy supplied to every resident and to any person acting on their behalf. We saw that the manager had started to copy the complaints procedure so that it could be given out to the residents at the home. It did not however have the correct information in it. We then asked to see the Statement of Purpose and the Service User Guide as we had been told previously that this had been updated. These documents should contain the Complaints Procedure. We asked 3 times to see these documents and then we were told that they were still on the computer and the computer was not working. Requirement not complied with. Requirement: The unguarded radiators must be covered or low surface temperature radiators fitted. The radiators had not been covered, however the time scale for action of the 29/01/2010 had not expired. Requirement: The remaining bedrooms must be redecorated and refurbished. Some bedrooms had been refurbished but not all, however the time scale for action of the 29/01/2010 had not expired. Care Homes for Adults (18-65 years) Page 7 of 22 Requirement: Adequate lighting must be provided. The requirement had not been complied with. Requirement: The lounge furniture must be thoroughly cleaned or replaced. The requirement had not been complied with. Requirement: The home must be kept secure. Throughout the day we saw that the front and back doors were left wide open on many occasions. The requirement had not been complied with. Requirement: The shower tray must be fitted in the shower room. The tray had not been fitted. It remained in the protective covering. The requirement had not been complied with. Requirement: The upstairs bathrooms must be redecorated and refurbished. The requirement had not been complied with. Requirement: People must smoke in the designated smoking area only and risk assessments in relation to smoking must be undertaken. We saw residents smoking throughout most areas of the home. The requirement had not been complied with. Requirement: Adequate staff must be provided. The inadequate staffing levels remain unchanged. The requirement had not been complied with. Requirement: Management must demonstrate to us that all staff are to be provided with all mandatory training and training specific to the needs of the residents. We were not shown any evidence of this. The requirement had not been complied with. Requirement: The registered person must ensure that the care home is conducted in such a way as to promote and make proper provision for the health and welfare of the residents. The care home is not conducted in such a way as to promote the health and wellbeing of the residents. The serious issues that we identified in relation to the medication system and the failure to meet the requirements of the last inspection evidence this. Requirement. Any incidents which may affect the well being of the residents must be reported to us. Management are required to send us notifications about any serious incidents that affect Care Homes for Adults (18-65 years) Page 8 of 22 the wellbeing of the residents. There have been 2 serious incidents that we have been made aware of and neither have been reported to us. During the course of this inspection we seized copies of the daily report books. On further scrutiny of them we found that in 1 instance the staff were made aware of a serious incident involving the safety and welfare of 1 of the residents but failed to seek timely medical assistance. We also identified that according to the medication administration sheet, 1 of the residents had not been given his medicines as regularly as he should have been. Shortly after the omission of his medications he was admitted to hospital having had a fit/seizure. The fits occurred on 2 occasions following omissions of medication. These are of serious concern and have been reported as safeguarding incidents to the local safeguarding adults coordinator. What the care home does well: What they could do better: The majority of the requirements from the last inspection remain outstanding. The manager and provider must address the requirements. These were issues in relation to: Care plans that still do not give enough information about the current and changing needs of the residents. Medical assistance must be summoned immediately when there is a risk to the health and welfare of the residents. The absence of risk assessments in relation to the hazards that could cause a risk to the health and safety of the residents and people working in or visiting the home. The lack of training for the staff in areas such as challenging behaviour, medicine management and the management of clinical and mental health conditions. The environment, which remains poor in the majority of areas. In addition the manager and provider need to ensure that: The menus improve. The menus offer very little choice of food. The meals are not varied and balanced. Some special diets are not catered for. Infection control procedures need to be adhered to, especially in the food preparation areas. This will help to prevent or reduce the spread of infection. All areas of medication handling are unsafe. Good quality policies and procedures must be in place to help staff handle medicines safely. Medication must be stored safely and securely at all times and in appropriate cabinets which meet current legislation. Records about all aspects of medication must be clear and accurate to show that medication is given properly and can all be accounted for. Details about how to give medication Care Homes for Adults (18-65 years) Page 9 of 22 prescribed as when required or as a variable dose must be recorded so staff can give medicines safely and consistently. Full assessments of risk must be recorded for people who look after some or all of their own medication some or all of the time. The unsafe practice of giving people medicines to take out in envelopes and other unlabeled containers must stop at once. All medication must be given as prescribed: this includes giving medication at the correct times and in the correct doses. Staff who handle medication must be properly trained and must be assessed as competent to administer medication safely. Unsafe medication practices put residents health and wellbeing at risk from harm. Management must make sure that a complaints procedure is in place to ensure that residents know who to complain to and to assure them that their concerns will be listened to. Enough staff must be provided at all times so that the assessed needs of the residents are met. The management must ensure the security of the residents and staff within the home. Management must ensure that the residents and staff do not smoke in non designated smoking areas. It is a fire risk and is not in accordance with the law. 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 2. Care Homes for Adults (18-65 years) Page 10 of 22 Are there any outstanding requirements from the last inspection? Yes R 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 15 Care plans must detail the health and social care needs of the residents. So that the current and changing health and social care needs of the residents can be met. 04/01/2010 2 7 15 Information recorded on the care plan should reflect the current and changing needs of people. Without this information there is no assurance their needs and wishes will be met. 30/09/2009 3 9 13 Staff must make sure that 04/01/2010 any risk to the health and safety of the residents is identified and action taken to reduce or stop any identified hazard. To ensure the health and safety of the residents. 4 9 13 Comprehensive risk 30/09/2009 assessments need to be reviewed and updated ensuring information is accurate. Where additional concerns have been identified these too should be included. Page 11 of 22 Care Homes for Adults (18-65 years) 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Providing staff with information about the level of support required so that people are kept safe. 5 17 16 A more varied menu must be 04/01/2010 provided that is nutritious and offers choice. Special diets must also be provided for. To ensure that the dietary and cultural needs of the residents are met. 6 17 13 Protective clothing must be worn when preparing and serving food. To help prevent/reduce the spread of infection. 7 19 12(1) Accurate records must be 30/08/2008 maintained with regards to peoples dietary needs as well as accurate monitoring of their weight ensuring they are supported fully and their health and well being is maintained. 04/01/2010 8 20 13 Effective arrangements must 22/12/2009 be put in place at the home to ensure that all medication records regarding receipt, administration and disposal are completed accurately. So that medicines can be fully accounted for to prevent mishandling. Records must Care Homes for Adults (18-65 years) Page 12 of 22 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action also show that medicines are being given correctly and peoples health is not at risk from harm. 9 20 18 All staff who administer medication must receive accredited medication training ensuring they have the competence needed to administer peoples medication safely. 10 20 13 Effective arrangements must 22/12/2009 be put in place at the home to ensure that all medication is administered to residents in exact accordance with the prescribers directions. Because receiving medicines at the wrong dose, wrong time or not at all can seriously affect their health and wellbeing. 11 20 13 Medication administration records must be completed in full along with explanations where medication has not been given ensuring people are given their medication as prescribed and their health and well being is not affected. 12 20 13 A Controlled Drugs cabinet must be obtained which complies with current 04/01/2010 30/08/2009 30/10/2009 Care Homes for Adults (18-65 years) Page 13 of 22 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action legislation under the Misuse of Drugs Act (safe custody) Regulations, and must be fixed to a suitable wall in compliance with that legislation. To ensure the safe storage of controlled drugs and to comply with legislation. 13 20 13 There must be an effective auditing process in place to ensure that managers are confident that medicines are being handled safely. To help make sure that people who live in the home are kept safe. 14 20 13 All medicines must be stored 31/12/2009 safely and securely. Medicines must be stored safely to make sure they can not be mishandled and put peoples health at risk 15 20 13 There must be effective systems in place to ensure staff that handle medicines are trained in medicines handling and are competent to do so safely. To help make sure that people who live in the home are kept safe. 16 22 22 A complaints procedure must 04/01/2010 be in place and a copy supplied to every resident and to any person acting on Page 14 of 22 31/12/2009 04/01/2010 Care Homes for Adults (18-65 years) 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action their behalf. So that people know how to complain and action is taken to listen to their concerns. 17 23 18(1)13(4) Arrangements should be 30/09/2008 made for staff complete Safeguarding training in relation to the local authority procedure so that they are aware of the procedure to follow ensuring people are kept safe. 18 23 23 Each of the bathrooms are in 30/11/2009 need of redecoration and refurbishment so that they provide comfortable, safe and clean facilities for people to use. 19 23 23 The sunken floor in the downstairs shower room need attention so that people are not placed at risk and further damage to the property is prevented. 30/08/2009 20 24 23 Adequate lighting must be provided. To ensure that the residents are able to live in comfortable and homely. surroundings. 04/01/2010 21 24 16 The lounge furniture must be 04/01/2010 thoroughly cleaned or replaced. Page 15 of 22 Care Homes for Adults (18-65 years) 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action To ensure the comfort of residents. 22 24 23 The remaining bedrooms must be redecorated and refurbished. For the well being and comfort of the residents. 23 24 23 The home must be kept secure. To protect the residents and staff from harm 24 24 13 Risk assessments must be in 04/01/2010 place for those radiators that are close to the residents beds. To reduce the risk of accidental burning 25 24 23 Each of the bathrooms are in 30/11/2009 need of redecoration and refurbishment so that they provide comfortable, safe and clean facilities for people to use. 26 24 23 The sunken floor in the downstairs shower room need attention so that people are not placed at risk and further damage to the property is prevented. 27 24 13 The unguarded radiators must be covered or low surface temperature radiators fitted. 29/01/2010 30/08/2009 04/01/2010 29/01/2010 Care Homes for Adults (18-65 years) Page 16 of 22 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action To reduce the risk of accidental burning. 28 27 23 The shower tray must be fitted in the shower room. To ensure that the residents are provided with a safe showering facility. 29 27 23 The upstairs bathrooms must 04/01/2010 be redecorated and refurbished. So that they provide comfortable, safe and clean facilities for people to use. 30 28 13 People must smoke in the 04/01/2010 designated smoking area only and risk assessments in relation to smoking must be undertaken. To reduce the risk of fire and protect the health and safety of the people in the home. 31 33 18 Rotas should be kept under review ensuring that sufficient staffing are provided to meet the needs of the service. 32 33 18 Adequate staff must be provided. To ensure that the assessed needs of the residents are met at all times. 33 33 18(1)(a) Staffing levels should be kept 30/08/2008 under review ensuring staff Page 17 of 22 04/01/2010 30/09/2009 04/01/2010 Care Homes for Adults (18-65 years) 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action are provided in sufficient numbers at times which best meet the needs of people living at the home. 34 34 19schedule 2 All relevant information and 30/08/2008 checks needs to be in place before staff commence any work at the home ensuring people are not placed at risk. 35 35 18 Management must 04/01/2010 demonstrate to us that all staff are to be provided with all mandatory training and training specific to the needs of the residents. To ensure that the staff have the knowledge,skills and competencies needed to support and care for the residents safely. 36 35 18 All staff must be provided with good quality training specific to the needs of people living at the home. This should include areas such as mental health awareness, challenging behaviour, epilepsy as well as mandatory courses. This is to ensure staff have the knowledge, skills and competences needed to support people safely. 30/10/2009 37 35 18(1)(c) (i) A programme of training 30/09/2008 Page 18 of 22 Care Homes for Adults (18-65 years) 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action needs to be developed for the forthcoming year so that staff receive all necessary training relevant to their roles and responsibilities ensuring they are competent to carry out their role safely. 38 37 12 The registered person must 30/08/2009 ensure that the care home is conducted in such a way as to promote and make proper provisions for the health and welfare of service users ensuring their safety and protection. 39 37 12 The registered person must 04/01/2010 ensure that the care home is conducted in such a way as to promote and make proper provision for the health and welfare of the residents. To ensure their safety, protection and well being. 40 39 24 Quality assurance systems need to be improved and clearly evidence that the service is being monitor and reviewed ensuring the improvements needed are addressed and a quality service is proivded. 30/09/2009 41 42 37 All incidents which may affect the well being of residents must be reported to us 30/08/2009 Care Homes for Adults (18-65 years) Page 19 of 22 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action evidencing the appropriate action has been taken. 42 42 37 Any incidents which may affect the well being of the residents must be reported to us. To show that the appropriate action has been taken. 43 42 37 Any incidents, which occur that may affect the wellbeing of people, must be reported to the CSCI in line with Regulation 37. 30/09/2008 04/01/2010 Care Homes for Adults (18-65 years) Page 20 of 22 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, 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 19 13 Medical assistance must be 28/01/2010 summoned immediately when an incident occurs that affects the health and well being of a resident. To ensure the safety, health and wellbeing of a resident. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 21 of 22 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got 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 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 22 of 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!