Inspection on 04/09/08 for Cregg Na Ba

This inspection was carried out on 4th September 2008.

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

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

Other inspections for this house

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Insight - Eastchurch

Southfields

Thorndene

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Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Cregg Na Ba Chain Lane Battle East Sussex TN33 0HG     The quality rating for this care home is:   two star good 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: Michele Etherton     Date: 0 4 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 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: Cregg Na Ba Chain Lane Battle East Sussex TN33 0HG 01424774707 01424751641 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Anthony William Simons Type of registration: Number of places registered: Hastings and Rother Primary Care Trust care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 6. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home 6 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. A key unannounced inspection of this service has been undertaken, this has taken account of information received from and about the service by CSCI since its change in Registration following the move from one PCT to another. The information we have looked at includes an Annual Quality Assurance Assessment (AQAA) completed by the home manager. The AQAA has been completed very professionally and contains a good level of detail providing us with all of the information we need to tell us about the everyday operation of the service, areas identified for improvements and future planning. Care Homes for Adults (18-65 years) Page 5 of 28 The inspection process includes an unannounced site visit to the service on 4/9/08 between 10:00 and 15:25. During this visit we toured the premises viewing communal areas and bedrooms. We consulted with three staff in addition to the manager. All residents were observed and acknowledged during the inspection although due to communication issues were unable to engage in conversation about the service they receive. We have received limited survey responses aout the service but have taken into consideration those received from a relative, staff member and GP, this information in addition to comments from staff on the day have been helpful in compiling this report. All key standards have been assessed in addition to any others where outcomes became apparent during the site visit. We examined a range of documentation during our site visit that included care records, risk assessments, menus, medication arrangements, staff training and supervision records, complaints information accident/incident reports and health and safety servicing and checks. The AQAA informed us that one adult safeguarding referral has been made and the manager reported at the site visit that this is now closed. In arriving at our judgment of the service we have been proportionate in considering where shortfalls currently exist and what evidence is in place to demonstrate that changes are already underway to address these issues, alongside the risks and impacts the identified shortfalls currently have for residents. We consider that satisfactory systems are in place to safeguard residents from harm and abuse as long as they are adhered to by home staff and they follow through with the proposed improvements What the care home does well: What has improved since the last inspection? Since the last inspection the home has re registered owing to its transfer to another PCT as a consequence of this any previous shortfalls have not been carried forward. The AQAA tells us that in the last 12 months the home has : introduced individualized user guides in a format suited to the resident. The garden has been further developed to include a sensory area and pergola. The dining room has been updated to provide a pleasant modern environment improved floor covering allows more through cleaning of the area. Carpeting in communal areas has also been replaced. Working in partnership with MCCH the service has been able to offer better choice of activities and these are more personalized, residents are being involved in quality audits of the service, menus have been reviewed with plans to develop pictorial versions. Family members are becoming more involved in supporting residents to medical appointments when appropriate. Recruitment of staff has improved with all vacant post now filled, managers now play an active role in the direct selection and recruitment of staff and residents are also provided with opportunity to be more involved and to have their views taken account of in respect of appointments. Care Homes for Adults (18-65 years) Page 7 of 28 Improved access to more specialist training for staff to meet and understand resident needs better. Improved IT equipment and access to the INTERNET 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 28 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 28 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. Residents are provided with accessible information about the service. They can be confident their needs will be assessed prior to admission to ensure these can be appropriately supported, they are provided with opportunities to visit. Some thought should be given to making information about the terms and conditions of their stay easier to understand. Evidence: The service ensures that existing and prospective residents have information about the service, provided in a format that best suits their communication needs. Residents of the home have communication difficulties and received help to complete surveys we sent to them, one response we received from a resident said Im glad I came here They did tell me about this place. Prospective residents can be assured that they will receive a comprehensive assessment of their needs and compatibility prior to admission to ensure they can be appropriately supported within the home, they will also have opportunities to visit. A staff survey response confirmed this reflecting that service users were involved in seeing the new bungalow they made several visits, a Care Homes for Adults (18-65 years) Page 10 of 28 Evidence: transition plan was in place Residents are provided with a copy of their license agreement which is in a standard format at present, where residents are considered to have capacity and are asked to sign the license agreement consideration should be given to providing the license agreement information in a more accessible format. Care Homes for Adults (18-65 years) Page 11 of 28 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. Residents can be confident that a support plan is in place that reflects their current needs, goals and aspirations and informs staff how they prefer and should be supported. Residents are enabled and supported through the use of good communication tools to make decisions and choices in their everyday lives, risk management strategies are in place but information is not always up to date. Evidence: A detailed and person centered plan of care is provided for each resident that reflects their preferred routines and specialist needs, it informs staff about how support is to be delivered Support plans focus more on opportunities and experiences for residents than individual goal setting, although residents are encouraged to utilise their skills and potential for independence in their daily routines. They have opportunities to make decisions and choices in their day to day lives as much as they are able or wish to, and their refusal to participate is respected. Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: Risk assessments information is in place but is not routinely updated, the home manager is aware of this and the deputy confirmed this is a task that she has been allocated to address. As there has been little evidence that residents have been placed at risk as a result of the outdated risk assessments and where events have occurred the home has responded appropriately to alert relevant agencies make referrals to other health professionals and minimized any similar occurrence a proportionate view has been taken and it is recommended that the home progress the update of risk assessments as planned. Care Homes for Adults (18-65 years) Page 13 of 28 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents enjoy a full and stimulating lifestyle, they are supported to maintain contacts with their families and friends. Residents are encouraged to maximize their independence and take an active role in the household. A healthy diet is promoted and residents will benefit from proposed improvements that enable them to make a more active choice in menu development and meal selection Evidence: Residents are provided with a varied programme of activities every day, this is developed to take account of their own likes, dislikes and interests and to enrich their lives by introducing them to new experiences that they can cope with. We examined daily records against against activity planners and found that residents were receiving planned activities or alternatives in keeping with programme, consideration should be given to providing pictorial references of alternatives to enable residents to make a Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: more informed choice. Residents make use of community facilities and enjoy a community presence in the local area. Staff reported that one resident is supported to attend church on a regular basis. Discussion with staff indicated that a number of the residents retain good relationships with their extended family who take an active interest in their welfare, in some cases accompanying residents to health appointments. The manager and staff welcome the involvement of family members and were positive about their input into individual residents lives. The home enables and facilitates residents to maintain contact with important people in their lives and opportunities are provided for them to receive and make visits. Residents are provided with an annual holiday supported by staff. Residents have their own rooms and where they are unable to manage a key a clear statement regarding this is recorded in the file. Staff were observed and heard using preferred forms of address to residents and undertaking 1-1 interactions and activities. Residents were able to move freely around the home and in good weather this extends to the garden too. Residents are encouraged to develop or maintain a level of independence and their involvement in day to day household tasks and routines is encouraged e.g cleaning their own bedroom, helping at mealtimes. Residents eat in a pleasant dining area, staff are aware of specialist diets and take account of this in menu preparation, discussions with staff highlighted an awareness that the menu has not offered the choice it should and changes have already started to be made to offer a choice on the written menu for the main meal, in practice records of food eaten do not support this, and this may be due to the menu information not being in a format that residents understand , staff indicated that they are already working on a picture reference menu system which will enable residents opportunity to make active choices between the meals shown, staff expressed enthusiasm for this work and recognized the need also to record resident food intake on a daily basis, it was agreed that the best place to record this would be in their daily records and we would urge that staff implement this along with the planned improvements. In view of the expressed knowledge and awareness of individual staff and their common understanding of what improvements are underway we have taken a proportionate view on this occasion that the home is well on the way to making the improvements needed and we need not issue recommendations or requirements for this to be implemented. Care Homes for Adults (18-65 years) Page 15 of 28 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. The Physical, emotional and health care needs of residents are supported. Evidence: We looked at personal support plans, and spoke with and observed staff working with individual residents. Communication guidelines are in place to enable staff to understand resident responses to delivery of care and support. Residents have Health Action Plans and are supported to access routine and specialist health care appointments, PCP planning meetings monitor access to health care and where additional health care needs are identified. We looked at medication storage administration and recording of medications and are satisfied that the arrangements currently in place safeguard the residents. Although controlled drugs are not in use at present, the home should be mindful of the need to provide appropriate storage in line with legislation at the time of their receipt into the home if they should be prescibed Care Homes for Adults (18-65 years) Page 16 of 28 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. A complaints procedure is in place but consideration should be given as to how this can better reflect the concerns of non verbal residents. Systems are in place to safeguard residents from harm and abuse. Evidence: Staff have an understanding of how and when residents are expressing distress and would investigate its cause. A more accessible version of the complaints procedure is displayed which has pictorial prompts for residents. Discussion with staff indicated that current residents are unable to make use of the complaints information or make known any concerns they may have, this is made clear when viewing complaints information where none of those recorded are from residents. Clearly with residents unable to vocalise their concerns, further consideration is needed in the way that incidents of distress, anger and frustration exhibited by residents are recorded and dealt with, whilst it is appreciated that this is a difficult area for staff a common sense approach must prevail and in those incidents where other more able residents would be likely to complain or express concern it should be similarly assumed that those unable to vocalise their concerns would wish to do the same, and staff should be mindful of this when dealing with incidents and working with residents. The recording of complaints would also benefit from review as to whether confidentiality is appropriately maintained. Care Homes for Adults (18-65 years) Page 17 of 28 Evidence: Staff receive training in POVA and this is updated every 3 years, staff expressed an awareness of adult protection issues and understand their reporting responsibilities and there is evidence that alerts are being escalated to senior management within the PCT and to the adult social care teams as agreed under the Sussex multi agency protocols. There are sound systems in place for the management of residents monies with external review and auditing occurring. Guidelines are in place to inform staff about how they respond to behaviors some residents may express. Any issues relating to behavior would be discussed within PCP meeting, referral to appropriate psychology support and psychiatrist can be evidenced, the home makes use of ABC monitoring for specific behaviors and this would be discussed with relevant health professionals. Care Homes for Adults (18-65 years) Page 18 of 28 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. Residents live in a clean, comfortable and well maintained home, they would benefit from suggested improvements to better maintain their safety. Evidence: We toured the home which is in keeping with surrounding properties, we found it to be bright and airy, providing pleasant modern and comfortable environment for residents. The residents have access to a pleasant patio area, in addition there is a large area left in a wilder state which is uneven and inaccessible to residents, this area is attractive to local wildlife and a source of interest to residents, whilst it is generally understood that residents would not access the garden unsupervised, thought should be given as to how the uneven garden area can be made safe for residents without them experiencing any loss of the visual stimulation they gain from it. The home is maintained to a good standard of redecoration and a programme of maintenance is in place.Staff and residents ensure the home is kept in a good state of cleanliness and appearance however, consideration should be given to more appropriate storage areas for broken items of furniture awaiting collection other than near to the patio area which is unsightly and potentially hazardous. Care Homes for Adults (18-65 years) Page 19 of 28 Evidence: Residents are able to influence the redecoration of their own rooms and these are pleasingly decorated with personal items displayed and fabric and furnishings to a high standard. Residents have over a number of years replaced original furnishings by purchasing much of their own furniture, it is anticipated that on all occasions these decisions have been made only following consultation with all relevant stakeholders to ensure this is an appropriate use of resident monies and in keeping with their own wishes, as we would not expect residents to routinely fund items we would normally consider to be the responsibility of the provider. We examined the fire log and this tells us that the home is maintaining fire alarm and fire fighting equipment ensuring that regular testing and servicing is undertaken however frequency of staff fire drills has slipped, and the home should ensure that staff paticipate in a minimum of two drills within a 12 month period. Care Homes for Adults (18-65 years) Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from improved levels and continuity in staffing to support their everyday care needs. The staff team are well trained to ensure they are aware of and understand the specific personal and health care needs of the residents. Staff performance has not been routinely assessed although the frequency of this is now improving. Evidence: The AQAA information tells us that staffing levels have improved. The manager advised that three staff are on duty during day time shifts with the manager or deputy in supernumerary capacity, these staffing levels were confirmed with staff during the course of our visit,, we reviewed the staff rota and this was accurate at the time. Staff told us that staffing levels have now improved with the filling of vacant posts ensuring greater continuity for residents and staff. We observed staff spending time with residents on an individual and group basis during the course of our visit. The AQAA completed by the home tells us that 70 of the staff team now have an NVQ2 qualification or above, a rolling programme of mandatory and specialist training Care Homes for Adults (18-65 years) Page 21 of 28 Evidence: is also in place to ensure staff are provided with or updated on the necessary skills and knowledge to support the resident group and the majority of staff have completed this. Staff recruitment files could not be examined at this site visit as these are kept centrally; Personnel files are to be examined in the near future by a CSCI representative at which time an overall judgment concerning the robustness of the recruitment procedure will be made. The manager advised that the recruitment process had improved under the new PCT in that managers are now more actively involved in the direct selection and recruitment process and residents are provided with opportunities to meet prospective staff and their views are taken account of. The Trust provides new staff with a structured induction plan over a two week period that includes shadowing expereinced staff, and some mandatory training. Those without NVQ qualifications and previous knowledge of Learning disabled adults are also required to undertake induction in keeping with skills for Care and this includes completion of LDAF. The training programme is managed centrally, and staff provided with dates for refresher training as needed, a system is in place to ensure that where staff miss training they are allocated to vacant slots at a later date. Individual training profiles are maintained for staff. A training matrix is kept updated providing a good overview of the level of skills and knowledge within the team. Staff told us that they have team meetings and that they find the management team approachable, an agency worker told us that they have been made welcome within the staff team, feel well supported and have been included in the supervision and team meeting programme which they value and appreciate. staff commented that : they are a really nice team and I feel really well supported The manager was so supportive of me A really nice team we get on really well A review of supervision records indicates that when undertaken this is fairly comprehensive although there is a need to evidence within these where observation of staff practice informs the supervision agenda and this has been discussed with the manager. Although happening the frequencies of supervisions had previously drifted. The manager acknowledges that previous staffing shortages have had an impact on Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: the frequency of supervisions and team meetings, but with the appointment of the deputy there is already evidence that improvements to frequencies are being made. Care Homes for Adults (18-65 years) Page 23 of 28 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Home is generally well managed and residents health safety and welfare protected and promoted, but if this is to be maintained and improved upon minor shortfalls identified should be progressed in a timely manner. Evidence: The present manager has been in post for some some years and has supported the staff and residents through the change from one PCT to another. The manager is about to undertake the Leadership and management qualification. Staff comment positively on the open style of management within the home, tell us they feel listened to and find the manager supportive and approachable. They are kept well informed of changes and developments. The home has now been provided with a computer and this has internet access ; staff we spoke with commented positively on this improvement and demonstrated confidence in using it for research and information to help their work with residents. Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: The trust has developed a series of resident engagement tools to gather resident responses about different aspects of the service, at present the manager is unclear how this information is to be analysed and influence overall service development. Some stand alone auditing measures already exist in respect of health and safety, medication, and resident finances, but as yet there is no evidence or staff knowledge of a cohesive system of internal audit and review of the service, that also incorporates user views. An annual published report of quality outcomes is also in need of development. It is recommended that these shortfalls are addressed. We viewed records of Provider visits and found that these are being undertaken regularly and detailed records maintained. AQAA infiormation tells us that whilst the service has access to a comprehensive range of policies and procedures many have not been updated for some time and were produced by the previous trust. Following the move to the new trust all policies and procedures are now subject to review and we noted evidence that this this is currently underway, as such we do not consider it necessary at this time to issue recommendations or requirements in this area. Accident and incident information is being maintained and notifications to other agencies made where appropriate, we noted one minor omission and this has been discussed with the manager, whilst we are satisfied that the incident has been managed appropriately we have urged the manager to refamiliarise himself and other staff with the range of events that must be notified to CSCI under regulation 37 of the Care homes Regulations 2001. The AQAA informs us that all health and safety checks and servicing have been undertaken and we confirmed this to be the case through examination of a random sample of servicing reports during the site visit. We noted that staff have not received fire drills this year although there is evidence this has been carried out previously,staff have received fire training but the manager is reminded of the need to ensure all staff participate in two fire drills within any 12 month period as a minimum, and agreed at the site visit to arrange for this to happen. Care Homes for Adults (18-65 years) Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 28 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 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 9 Risk assessment information to be updated in keeping with PCP reviews as a minimum to ensure that any changes in need are taken into account in risk review, the format should also be reviewed to ensure that sufficient detail is recorded to evidence how judgments have been arrived at in achieving risk reduction. There is a need for the home to develop internal systems for the audit, planning and review of service delivery which takes account of user views. The service should progress analysis of quality measures and publish a report annually available for inspection 2 39 Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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