Inspection on 06/10/08 for Cumberland Avenue Residential Home

This inspection was carried out on 6th October 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cumberland Avenue Residential... 06/12/06

Cumberland Avenue Residential... 16/02/06

Cumberland Avenue Residential... 14/07/05

Cumberland Avenue Residential... 31/01/05

Cumberland Avenue Residential... 11/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Cumberland Avenue Residential Home 31 Cumberland Avenue Bury St Edmunds Suffolk IP32 6TG     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: Claire Hutton     Date: 0 6 1 0 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 27 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 27 Information about the care home Name of care home: Address: Cumberland Avenue Residential Home 31 Cumberland Avenue Bury St Edmunds Suffolk IP32 6TG 01284725972 Telephone number: Fax number: Email address: Provider web address: caroline.smith@mencap.org.uk Name of registered provider(s): Name of registered manager (if applicable) Mrs Caroline Joyce Smith Type of registration: Number of places registered: Royal Mencap Society care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Date of last inspection Brief description of the care home 31, Cumberland Avenue is a six-bedded care home for adults with learning disabilities. It is located in a residential part of Bury St. Edmunds and is situated in a quiet road with access to green areas nearby. The home is close to local shopping facilities and a short car or bus journey from the town. Mencap provide the staffing and administration and lease the home from Suffolk Housing Association. The home has a detailed statement of purpose and service users guide, which provide information about the services provided. Each resident is issued with a licence to occupy setting out their basic rights and responsibilities with the Housing Association and Mencap. The current fees range between 597.97 and 806.73 per week. More up to date information can be obtained directly form the home. 6 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 27 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 inspection was unannounced and took place on a weekday afternoon and early evening lasting 6 hours. This was a key inspection, which focused on the core standards relating to adults, aged 18-65. The report has been written using accumulated evidence gathered prior to and during the inspection, including 6 completed surveys called ‘Have your say about’ Cumberland Avenue. A selfassessment devised and requested by us was completed by the manager and returned before our visit. We had one survey completed by a staff member returned to us and 2 more staff were interviewed in private during our visit. We examined a number of records including those relating to residents care plans, staff recruitment, training and health and safety records. The registered manager was not available for this inspection, but the deputy manager was helpful and knowledgeable. Care Homes for Adults (18-65 years) Page 5 of 27 Care Homes for Adults (18-65 years) Page 6 of 27 What the care home does well: What has improved since the last inspection? 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 7 of 27 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 8 of 27 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 this service can expect to have information about this service and be consulted before they choose to move in. They may not find that a full assessment is completed before they move in. Evidence: Since our last inspection of this home in 2006 the home had admitted one new resident. We requested to look at the information and assessment complied before this person moved into the home that allowed the home to make the judgement that they could meet that persons needs. However this was not available. We were told however that as much information as possible was obtained from visits and meetings prior to the person moving in to the home. All six of the residents told us that they were asked if they wanted to move into the home and that there was enough information about the home to help them decide. Residents told us, I like it here very much. I think its nice. The information I got was good. The statement of purpose and service user guide provided detailed information about Care Homes for Adults (18-65 years) Page 9 of 27 Evidence: the home’s admission procedure, which was supported by Mencap’s admissions policy. The statement of purpose and service guide had been updated in 2006 to reflect that one resident had developed the condition of dementia and was being supported to continue to live at the home. Professionals had visited the resident at home to assess the environment and have developed a plan of care that will continue to meet the residents needs. A representative from the Alzheimer’s society has provided training for staff to ensure they have the skills and experience to understand the changing needs of the resident. The self assessment completed by the homes manager said that the licence to occupy issued to the residents had up to date fees on it, but staff at the time of inspection were not sure about this. Care Homes for Adults (18-65 years) Page 10 of 27 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 expect to have care plan’s that reflect their lives, personal goals and identify their changing needs. They can also expect to be supported to take risks, which enable them to lead positive and fulfilling lives. Evidence: Care plans seen were comprehensive covering all aspects of residents health, social and welfare needs. Staff spoken with said that the care plans contained enough information for them to provide the right amount of support. One staff member said There is a lot of great information and I have read through the risk assessments and support plans. Another staff member said The plans are good because the residents were heavily involved with them. The self-assessment completed by the manager had told us plans were person centered and designed by the resident and Key worker and that some of these we have made into photograph style in order that the service user can go through them with staff. We looked at care plans and found that this was the case. Photographs had been taken of the individual resident being supported in each Care Homes for Adults (18-65 years) Page 11 of 27 Evidence: aspect of daily living. This included activities in the home such as cooking and going out in the community to the bank and dealing with money. Support plans identified the level and support residents required and the interventions staff needed to take to meet their individual needs. These described the residents daily routines stating what they could do for themselves, their preferences and activities they participated in. These were linked to a range of assessments, which enabled the residents to take risks, for example preparing food and accessing public transport. Risk assessments were discussed and agreed with the resident to minimise risks and ensure their personal safety but still allowing them to take part in their chosen activity. Risk assessments showed that residents had limited understanding of financial matters and required support to manage their finances. A financial folder and personal money records of all transactions are maintained and showed that residents were in receipt of benefits. Each had a current and savers account and had standing orders arranged for payment of rent and fees. All transactions require two staff signatures. The records and balance of the residents money was regularly checked and found to be accurate. The self assessment also told us that Resident Meetings are held - prior to staff meeting - results are discussed at staff meetings and steps taken to implement service users wishes. Service users often invite themselves to the staff meetings to tell the team of their current issues. We found that this was the case and this process of actively listening to the residents was happening that week with key workers speaking to individual residents about issues they had for the staff meeting planned that week. Care Homes for Adults (18-65 years) Page 12 of 27 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 continue to be supported to have appropriate and fulfilling opportunities and to mix with other adults in appropriate activities within the local community. Evidence: Throughout the home there are various photographs of residents participating in many activites, social events and holidays. The self-assessment told us of some of the activites that were in place for the residents. We have reviewed Direct Payments twice in the past year. Once in December and also in July.We have purchased for three Service Users placements at an enterprise in Thetford where they are all extremely happy. One of the residents has one day day care at home with a designated staff on that day - which again they are extremely happy with.One of the Service Users has a placement at the Wood n Stuff Centre.On a Friday four of the Service Users access the Leisure Centre where they have organised activities supported now by staff who are Care Homes for Adults (18-65 years) Page 13 of 27 Evidence: aware of their needs. Paid for by Direct Payments. These oppotunities were confirmed by staff who spoke of the varying day care choices and from the daily routines set out in care plans. Residents confirmed that they can do what they want during the day, evening and at a weekend. One resident said I like watching television and going out at a weekend. Another resident said I like to go to the cabin at the weekends. A third member of staff was regularly seen on the roster for a Saturday to offer more choice when going out at a weekend. Staff confirmed that resdients had been on holiday this year. Within the home there are a variety of activites on offer. Individuals bedrooms were full of diffferent possessions which reflected choices of how individuals spent their time. The conservatory was the hub of art and craft with several art pieces hanging on the walls of the home. Currently being developed was a wall hanging to hold individual post as it arrived to keep it safe until resdients claimed it. Residents were able to maintain contact with friends and family. Many family photographs, postcards and letters around the home and in resdients rooms confirmed this. One resident regularly went home to their parents for the weekend and another resident had regular contact with a befriender. A roster on the fridge door showed that residents had responsibility for household chores with designated tasks to be undertaken each day. These included assisting with the preparation and cooking of meals and packed lunches, washing and drying up, laying the table, cleaning surfaces and emptying the dishwasher. We saw one resdient hoovering and others helping clear away after a meal and taking clean laundry to their rooms. The self-assessment spoke of healthy eating within the home. We found that the menus on offer did provide a varied diet based around healthy eating whilst giving the residents choice. A dietician had been consulted and staff had received training in this area. The main shopping was done on the internet with input from the residents. One resident told us I like the food that is cooked and that I can choose what I would like sometimes. Care Homes for Adults (18-65 years) Page 14 of 27 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can expect to be protected by the homes medication procedures and have their health and emotional needs met in partnership with professional specialist support. Evidence: Support plans identified the health and personal care needs of the residents and their preferences of how and when they required staff support. Daily records confirmed residents were being supported to access health professionals when required and their health needs were being monitored. An ongoing record of dates for health visits was kept including visits made to or by the General Practitioner (GP) and the details of care and medication prescribed. There were also records of appointments with other professionals such as dentist, hospital consultants, chiropodist and optician. That morning a resident had been accompanied to hospital for a check up having seen a GP earlier in the week. One resident also had a care plan in place to give to hospital staff should they require a hospital stay. Care Homes for Adults (18-65 years) Page 15 of 27 Evidence: Residents medication was kept in the staff office in a locked cupboard. The protocol for administration was in front of the medication file. each chart had a photograph of residents for identification. Staff administer medication to the residents and evidence was seen that the Medication Administration Records (MAR) charts were being signed appropriately and those seen were accurate and up to date. In one case a residents medication had been changed. Staff had the GP sign and alter the MAR sheet to enable them to give the new prescription. Also available to staff were information sheets on each medication for them to spot any signs of reaction or intolerance. Staff responsible for administering medication have received appropriate care of medicines training. The home has a homely remedies protocol, which informs staff to contact the GP before administering these medicines, and that records must be kept of any medicines administered. Care Homes for Adults (18-65 years) Page 16 of 27 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. Residents are protected and listened too and their concerns are taken seriously. Evidence: This service had a complaints procedure in place and a log of complaints. In the last 12 months the service had received no complaints. All 6 residents told us that they know who to speak to if unhappy. One resident said the manager helps me if Im unhappy. Another resident said staff help me if I have a problem or an unhappy and try to cheer me up. Staff spoken with were aware of Mencaps procedure and knew how to direct residents through this and listen to residents concerns. Staff also spoke of the benefit of the resident meetings should there be more than one person with the same concern, then the residents meetings could also be used to make changes. The organisation’s policy and procedure were very clear and detailed of staff’s responsibility to report allegations or suspicions of abuse to the Local Authority Vulnerable Adult Protection Committee (VAPC) and informing the Commission for Social Care Inspection (CSCI). To ensure residents were protected from abuse and neglect, all staff have a Protection of Vulnerable Adults (POVA) first and Criminal Records Bureau (CRB) check undertaken prior to taking up a post. Staff spoken with confirmed they were aware of the Whistle blowing and Adult Protection procedure. They confirmed they would report any concerns about abuse to Care Homes for Adults (18-65 years) Page 17 of 27 Evidence: the manager. Staff confirmed they had received updated training the protection of vulnerable adults. Care Homes for Adults (18-65 years) Page 18 of 27 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. The home provides an environment, that is well maintained, pleasantly decorated and is appropriate to the specific needs of the residents. Evidence: This care home was situated in a quiet road and was in keeping with the other houses. It consisted of six bedrooms with a large open plan communal living area comprising of dining area, lounge and kitchen leading through into a conservatory. The conservatory had recently been upgraded. There was a separate utility room. All corridors were wide to facilitate a wheelchair user living in the home. There were five bedrooms on the first floor and one on the ground floor with wheelchair access with an en-suite bathroom. The bedrooms were fitted with wardrobes, a lockable cupboard and a washbasin. The home was kept clean, warm and tidy and has no unpleasant odours. All areas of the home are nicely decorated, in bright and cheery colours. Furnishings and fittings were seen to be of good quality and domestic in nature adding to a comfortable and homely environment. A stair lift is provided for residents that cannot use the stairs to access the upper floor. Care Homes for Adults (18-65 years) Page 19 of 27 Evidence: This was serviced in January this year and is in good working order. A resident had their own ceiling hoist that went from bedroom to shower room. This had been serviced in February this year. This en-suite shower room contained a shower bed, which raised and lowered. It had a covered waterproof mattress and bumpers for the comfort of the resident. The overall décor and maintenance in the home was good. Bedrooms had recently been decorated. Whilst we were visiting a resident was having a new floor covering fitted to their bedroom. New furniture was in place and more ordered in terms of special raise and fall beds, recliner chairs and fitted bedroom furniture. One resident also had a special TV service installed through the BBC for people who were sight impaired. The service gave a commentrary to what was happening on screen. Staff said how this had improved the quality of this persons TV viewing experience. Water temperatures were being recorded and there was evidence to show these were tested and found to be within the safe recommended temperature of near to 43 degrees centigrade. A good supply of plastic aprons, disposable gloves, liquid hand soap and paper towels were available in all bathrooms and toilets. The laundry room was clean and tidy. A disposal of body waste procedure was displayed in the laundry, which guided staff to put clinical waste into the yellow bags provided. These were collected weekly. All soiled clothing and bedding was put through the sluice cycle in the washing machine and seen in operation that day Care Homes for Adults (18-65 years) Page 20 of 27 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 can expect to be supported by a staff team that are trained and have the skills and knowledge to care for them, well recruited and available in sufficient numbers to meet their needs. Evidence: We looked at the roster and self-assessment sent to us. The home employs 7 care staff all of whom had an NVQ qualification in care. There was always 2 staff on duty during the day, but on a Saturday this went up to 3 staff. At night a staff member stays overnight. Sleep in staff stay in the upstairs room that doubles as a staff office. The home employees were all female staff. There is always a manager on call. Observations made and comment from resident show that staff had a good relationship with residents. One resident said I like the staff that help us. The whiteboard in the dining room had a photo roster that was also colour coded so that residents could see who was on duty when. There was also a group photo for residents to see when a staff meeting was taking place. Staff meetings held and minutes seen reflect that regular monthly staff meetings are taking place. Staff spoken with confirmed they received good training opportunities and the right training to enable them to do their job. From speaking to staff and looking at records Care Homes for Adults (18-65 years) Page 21 of 27 Evidence: we saw that staff were trained in 1st aid, fire, moving and handling and medication. Two staff has attended medication training that day and a new staff member was completing her skills for care induction standards. The self-assessment, talking to staff and staff files seen confirmed the home was obtaining all the appropriate paper work relating to proper recruitment of staff including Protection of Vulnerable Adults (POVA) checks, references and criminal record bureau checks (CRB). Staff spoken with told the inspector that they receive regular supervision, however, records show that supervision of staff does not meet the recommended minimum of six sessions per year. Care Homes for Adults (18-65 years) Page 22 of 27 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. Residents can except to live in a home that is effectively managed and protects their health, safety and welfare. Evidence: Cumberland Avenue had a manager and a deputy manager. The manager was unavailable for the inspection. The deputy manager was on duty and was most helpful to the inspection process. The deputy manager had a wealth of experience working with people with learning disabilities and has worked at the home since 1997. The registered manager has NVQ 4 and the Registered Managers Award. Staff spoken with found the management team were approachable and supportive. One staff member said the manger was professional, friendly and evenhanded. Issues are solved. Mencap had devised a continuous improvement plan that staff use to provide information on what the home needs to do to improve, how this will be achieved, how areas of improvement were identified, who needs to be involved and when and what can be done to make things better. The deputy showed us the recent results that were Care Homes for Adults (18-65 years) Page 23 of 27 Evidence: regularly updated. She said this was a clear development pathway for the home to follow and we know its going to be checked up on. Indeed this was monitored by a senior manager within Mencap who visited regularly to complete the monthly Regulation 26 visits that shows us that the organisation is regularly assessing the quality of service within the home. The deputy confirmed these visits were unannounced. In relation to seeking the residents views the process in place of residents meetings that feed into staff meetings was meaningful. Residents were also consulted and part of new staff selection, therefore this showed that residents views were considered within the development of the home. Health ans safety matters were commented upon in the environmental section of this report however, we also found fire safety risk assessments had been completed and updated this included the evacuation of residents including methods and equipment of evacuation for physically disabled persons at night. The fire system had been serviced within the last week. The accident book was seen, this was used for residents and staff. Records were still in the book and not confidentially stored in line with the Data Protection Act. The deputy told us of 2 recent incidences where a resident and a staff member on 2 separate occasions had fallen on the stairs and that these had been reported to health and safety under RIDDOR (Reporting of Injuries, Diseases and dangerous Occurrences Regulations 1995) However the report for the resident falling had not been totally completed on the accident form and the accident form was not available for the staff member. The deputy manager believed that the incidence of the staff member had been reported to RIDDOR using the on line computer system. Care Homes for Adults (18-65 years) Page 24 of 27 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 27 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 41 17 Accident records must be available for inspection, completed fully and stored in line with the data Protection Act. This will ensure that residents rights and interests are safeguarded by the homes record keeping procedures. 17/11/2008 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 A full needs assessment should be completed before admission so that the home is sure they can meet those care and support needs. A record should be made of all formal supervision given to evidence that it is taking place and also to record decisions made. 2 36 Care Homes for Adults (18-65 years) Page 26 of 27 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. Care Homes for Adults (18-65 years) Page 27 of 27 - 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!