Inspection on 07/07/09 for Coatham Nursing Home

This inspection was carried out on 7th July 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coatham Nursing Home 30/06/10

Coatham Nursing Home 10/07/08

Coatham Nursing Home 31/07/07

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Coatham Nursing Home Coatham Road Redcar Cleveland TS10 1RA     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Valerie Daly     Date: 0 8 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Coatham Nursing Home Coatham Road Redcar Cleveland TS10 1RA 01642482208 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: vinodhukkeri@yahoo.co.uk Gradestone Limited care home 21 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 Coatham Road is a 21-bedded care home for Adults aged 18-65 who has a mental disorder. The home is a converted property on three floors with the majority of bedrooms being on the first and second floors. There are fifteen single bedrooms and three double bedrooms. On the ground floor there are two lounges, as well as the kitchen and dining room. The home is situated near to Redcar town centre and is within short walking distance from the beach. It has easy access to local amenities and is directly on a bus route. Many of the Residents have lived in the home for a number of years. The home charges fees in the range #354 to #500 per week. 21 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 29 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: The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This key inspection was to check that the home meets the standards that the Care Quality Commisssion say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. This inspection was conducted by two inspectors in one inspection day. During the inspection, a number of records were looked at, including records of people who use the service, along with staff recruitment and training records and maintenance. There was also discussion with the manager and staff who work at Coatham Rd. Care Homes for Adults (18-65 years) Page 5 of 29 Discussion also took place with people living at Coatham Rd. The manager had completed the Annual Quality Assurance (AQAA), the services selfassessment of how well they think they are meeting standards. This was received prior to the inspection. We have reviewed our practice when making requirements to improve national consistency. Some regulations 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 the services are not being put at risk or harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Care Homes for Adults (18-65 years) Page 6 of 29 What the care home does well: What has improved since the last inspection? What they could do better: More specific care plans need to be developed, particularly for more acute or challenging needs. Care plans should also be evaluated regularly. All incidents which affect the well being of people who use the service must be reported to the Commission via a Regulation 37 notice. Incidents of suspected abuse must be processed through Safeguarding People. In the environment some of the chairs in the main lounge were stained as they had been at the last inspection despite being regularly cleaned. The zips on the cushion parts of the chairs were broken. The carpet was stained and had cigarette burns in it. Care Homes for Adults (18-65 years) Page 7 of 29 The manager said the owner was considering replacing the carpet with laminate flooring. Consideration should be given to having an accessible toilet for more dependent people. There needs to be further mandatory training carried out in Health and Safety, COSSH and First Aid along with Safeguarding People. It was also recommended that staff receive training in Challenging Behaviour. The manager should have some supernumary hours to ensure he is able to carry out the administration work in the home. When the registered provider visits the home monthly he must complete a written report, (regulation 26). This will ensure that the home is being managed effectively and ensuring the best interests of the people living there. The results of the quality assurance surveys, carried out by the provider must be available to the people who us the service and the Commission. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 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 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have their needs assessed prior to admission. Evidence: Three sets of care files were examined. From the previous inspection the manager had developed further the assessment documentation. People at the home have all lived there for a number of years therefore there was no pre assessment documentation to look at . However the manager had reviewed and updated the peoples physical assessment documentation in June and July 2009. Care Homes for Adults (18-65 years) Page 10 of 29 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 at Coatham Nursing Home have care records which generally gives staff the information needed to show how their needs are to met and how they are to be supported and are able to make decisions. Additional information and more updating particularly following incidents of increased risk would strengthened these further. Evidence: People who use the service have individual care records in place, which include an full assessment of need and some supporting risk assessments. In the three files examined, a number of care plans were in place where a need had been identified. However, it was identified that there was the need to develop more specific care plans, particularly for more acute or challenging needs. For example, one person had two incidents of aggressive behaviour but there was no detailed risk assessment, risk management strategies and there was not a care plan in place for this dealing this area of need and the action that staff should take. In the care files examined the care plans had been evaluated monthly, up until March Care Homes for Adults (18-65 years) Page 11 of 29 Evidence: 2009 when the evaluations stopped. Risk assessments were in place where the majority of risks had been identified. However one person had a risk assessment in place for a fire hazard as a smoker. They attempted to set fire to the curtains and whilst there was evidence to show that the risk assessment was reviewed it had not been updated following the incident. The same person also had a risk assessment in place for absconding. This had been reviewed in November 2008 but not since then. Care Homes for Adults (18-65 years) Page 12 of 29 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 at the home are supported by staff, while maintaining links with their families and friends. They are able to make choices about their lifestyle. However this is limited for some people. Evidence: Since the previous inspection the manager and staff had sourced more available activities in the community. However there was a reluctance by the people who use the service to try new things. From discussion with the manager and staff it was felt that more would be achieved if the home had an activities organiser. Since the previous inspection, use of the documentation had progressed and plans were in place for social, recreational and occupational needs. Discussion took place with some of the people who use the service. There had recently been a day trip to Whitby. The people who had chosen to go said they had a good Care Homes for Adults (18-65 years) Page 13 of 29 Evidence: time and enjoyed the fish and chips. Three people said they would like more trips, whilst one person said a day out would be too much. One person said he keeps himself busy, goes to local shop for the staff, bingo twice a week, crosswords, likes reading and is a member of the library. He said he is able to make his own decisions and can come and go as he pleases. Another person said he likes to go to college, where he does pottery, making owls and plates. He also likes to visit his family, who live locally and attends church twice weekly. There is also advance community work twice a week , where he talks to people. One person said they were quite happy in the home, settled, their family member is able to visit. Nothing to improve, the best thing was plenty cups of tea and coffee. Another person talked about his week away at Rothbury RAF, for ex-servicemen and how he enjoyed the break. He also receives a visit from an RAF visitor every three months. One person had been awarded Learner of the Year in his gardening group. Since the previous inspection it was noted that there was improvement in the menus, offering more choice and variety. People who use the service were also being offered a hot tea four evenings a week. It had been recommended that advice should be sought from the Community Dietician. The manager said that the Dietician was attending the home in August 2009 and changes to the menu had been made following discussion with the cook. One person who uses the service thought the meals were quite nice, two choices were offered and you got your fill. Another person said the meals were good, well presented. There is a choice with sufficient quantities. Care Homes for Adults (18-65 years) Page 14 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have personal support when they need it so they can be as independent as possible. Medical healthcare needs are met, which ensures that people stay healthy, however there is the need to ensure that appropriate action is taken to ensure people Mental Health needs are effectively monitored and other health care professionals involved. Evidence: From discussion with people who use the service and reading care files, there was evidence to show that in the main health care needs were being met. However one person had been involved in incidents where they had punched another person. These incidents had not been reported via a Regulation 37 form to the Care Quality Commission or processed through Safeguarding People. Discussion took place with the manager who agreed that the persons behaviour had really just been accepted rather than investigated and follow up action taken. Advice was given that the persons Community Psychiatric Nurse needed to be involved along with the Consultant Psychiatrist. It was also recommended that the manager undertakes a full review of incidents, dates, times and action taken. On the day of the second visit for inspection the manager was in the process of arranging an appointment with the consultant for Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: the person who was displaying aggressive behaviour. In two of the care plans the persons blood pressure had been taken four times since the beginning of the year. There was often a noticeable difference in the readings. However there were not any signatures to show who had undertaken this procedure, no details to show that the differences had been noted and action taken and the manager said he had not been informed of any concerns. The home has policies and procedures in place for the ordering, receipt, storage, disposal and administration of medication. Since the previous inspection there is also a policy procedure and risk assessment in place for people who may wish to self medicate. At the time of the inspection there were no people who were self medicating. Care Homes for Adults (18-65 years) Page 16 of 29 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. People who use the service are able to express their concerns and have access to a robust complaints procedure. Appropriate action has not always been taken to ensure that people who live at the home are protected from abuse. Evidence: The home has a complaints policy in place which had been developed further since the last inspection to include details of Social Services Contracts and Commissioning Department. Discussion took place with people who use the service who said they would talk to a member of staff if they had a complaint. One person said the staff are good, if you have a problem tell them, they will sort it out, very friendly, they all have their own good ways. Since the previous inspection the safeguarding procedure had been updated and included information regarding the steps to be taken in the case of suspected abuse. However incidents had taken place in the home where one person using the service had punched another person. The incidents should have been reported to safeguarding and had not been. These were discussed with the manager who was advised to discuss retrospectively with the local safeguarding unit. Two members of staff interviewed said they would report any cases of suspected abuse to the manager. One member of staff said she had received training regarding safeguarding whilst she had been employed at the home, the other person had Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: received training during previous employment. Care Homes for Adults (18-65 years) Page 18 of 29 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. People who use the service live in a comfortable, clean environment. Some additional improvements would enhance the environment further. Evidence: A tour of the home was carried out. In the main lounge the chairs were stained as they had been at the last inspection despite being regularly cleaned. The zips on the cushion parts of the chairs were broken. The carpet was stained and had cigarette burns in it. The manager said the owner was considering replacing the carpet with laminate flooring. It was also identified that there was the need to find a more discreet way to deal with managing problems with continence in the home. The bedrooms contained personal items, some had more than others depending on what the person wanted. In a double room there was not a ceiling suspended privacy screen in place, which would ensure dignity is maintained. There was a mobile screen in the corner of the room. The small bedroom windows in the doors of the bedrooms remain painted out, which does not give the bedrooms a homely feel. A hoist had been purchased for a person who had become physically frail. Whilst this could be used to enable the person to use a commode they would be unable to be taken to a toilet as the only one on the ground floor is too small to accommodate a Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: hoist. Consideration should be given to having an accessible toilet for more dependent people. The flooring in the toilet and bathroom on the ground floor needs replacing. The people who wished to smoke continue to use the wooden building outside, however staff are unable to supervise them at all times. This is where the incidents of physical aggression have taken place. All areas of the home were clean and tidy. Care Homes for Adults (18-65 years) Page 20 of 29 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. There is a recruitment policy and procedure to protect the people who use the service. There needs to be sufficient members of staff on duty to meet the needs of the people who use the service. Evidence: The home has a recruitment policy and procedure in place. Since the previous inspection a new cook had commenced employment. The required information, references and CRB were in place prior to this person commencing work in the home. This was confirmed during a staff interview. Within the staff file there was an interview checklist and comments made by the manager, who conducted the interview. Two members of staff were interviewed. They both clearly enjoyed their work and said everyone worked together, supported each other. One person said that having a senior carer had provided more organisation and she felt the people who used the service were happier. At the time of the inspection there were five carers employed in the home. They had all achieved NVQ level 2 or above in care, which is more that the expected number. Since the previous inspection training had been carried out, Medication Awareness for 5 people, Moving and Handling for 5 people, Sensory Deprivation from the local Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: opticians and the manager had undertaken 2 days training in the Protection of Vulnerable Adults. There needs to be further mandatory training carried out in Health and Safety, COSHH, and First Aid along with Safeguarding People. It was also recommended that staff receive training in Challenging Behaviour particularly regarding the recent incidents. Staff interviewed said they received supervision regularly and there was a system in place. Care Homes for Adults (18-65 years) Page 22 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is in the main well run, however additional systems should be developed to show that people views are sought and that people are kept safe and free from harm. There must be evidence that the views of the people who live at the home are sought on how the home is run, so they know their views are valued and are used to improve the service. Health and Safety training is required to ensure the people who live at the home are safe from risk of harm. Evidence: The manager is a Registered Mental Nurse and has managed the home for a number of years. He said he is halfway through the Leadership and Management Award and hoped to complete it by the end of 2009. However this has been oustanding since the previous inspection. The duty rota was examined as part of the inspection. It showed that the manager continues to work excessive hours. Twelve hours Monday to Friday and six hours every other weekend. There is no supernumerary hours within his working hours. Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: The manager said that the Registered Provider visits the home regularly and is available for advice. However he does not provide a written report to inform the manager and the Care Quality Commission of his findings, a regulation 26 report. For quality assurance, the manager said that there is a system in place. Only recently the Registered Provider had sent surveys to the home to be completed by the people who use the services. The manager said he had returned them the week before the inspection. However the results of the information gathered from the surveys is kept at Head Office and not shared with the people who use the service, relatives and staff or the Care Quality Commission. There was evidence to show that a meeting had been held for people who use the service at the beginning of July. This was well attended, activities, meals and outing were discussed. A meeting for staff had also taken place at the beginning of July and minutes were available. A random selection of personal allowances were checked. The systems used for looking after peoples monies are good. Receipts are kept when any money is spent on behalf of the person. Monies are audited every evening by two members of staff. Health and Safety policies are in place in the home. Staff training records were examined and there was no evidence to show that training in health and safety had taken place. Discussion took place with the manager regarding training and he said he had found an training agency who carry all mandatory training. He was awaiting confirmation of when training in health and safety would be carried out. Maintenance records were examined regarding water temperatures, fire checks and PAT tests were up to date. Care Homes for Adults (18-65 years) Page 24 of 29 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 25 of 29 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 19 12 All incidents which affect the 07/10/2009 well being of people who use the service must be reported via a regulation 37 notice or processed through safeguarding people. This is required to safeguard the people who use the service. 2 19 12 Where staff are undertaking medical checks of people who use the service. They must sign to say they have carried out the procedure and inform the manager if they have any concerns of the outcome. This is required to safeguard the people whose the service. 07/10/2009 3 23 13 Incidents of suspected abuse 07/10/2009 must be processed through safeguarding people. Care Homes for Adults (18-65 years) Page 26 of 29 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 This is required to safeguard the people who use the service. 4 35 18 Staff must receive training in Health and Safety, COSHH, First Aid and Safeguarding People. This is required to safeguard the people who use the service. 5 38 24 The results of the quality assurance surveys, carried out by the provider must be available to the people who use the service and the commission. This is to ensure that the views of people who use the service are listened to and acted upon. 6 39 26 When the registered provider visits the home monthly, and talks to staff and people who use the service he must complete a written report (regulation 26), a copy of which should be in the home. This will ensure that the home is being managed effectively and ensuring the best interests of people living there. 07/10/2009 07/10/2009 09/10/2009 Care Homes for Adults (18-65 years) Page 27 of 29 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 6 6 Care plans should be evaluated regularly. For some people who use the service, more specific care plans need to be developed, particularly for more acute or challenging needs. Risk assessments should be reviewed regularly and updated when required. Chairs should be repaired or replaced where the zips are broken on the cushions and they are stained despite being regularly cleaned. Consideration should be given to having an accessible toilet for more dependent people. There should be privacy screens in double bedrooms. Consideration should be given to replacing the carpet in the main lounge where there are cigarette burns. Staff should receive training in challenging behaviour particularly regarding recent incidents in the home. The manager should have some supernumary hours to ensure he is able to carry out the administration work in the home. The manager should complete the Leadership and Management Award by the end of 2009. 3 4 9 24 5 6 7 8 9 24 24 25 35 37 10 37 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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