Inspection on 21/04/09 for Devon House

This inspection was carried out on 21st April 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Devon House 22/04/08

Devon House 07/11/07

Devon House 21/05/07

Devon House 05/05/06

Devon House 24/02/06

Devon House 22/09/05

Devon House 19/10/04

Devon House 17/06/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Devon House 49 Bramley Road Oakwood London N14 4HA     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Wendy Heal     Date: 2 1 0 4 2 0 0 9 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. 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. 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 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Devon House 49 Bramley Road Oakwood London N14 4HA 02084470642 02088864408 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Parkcare Homes Ltd care home 14 Number of places (if applicable): Under 65 Over 65 0 0 dementia mental disorder, excluding learning disability or dementia Additional conditions: 1 14 The maximum number of service users who can be accommodated is: 14. The registered person may provide the following category/ies of service only: Care home only - Code PC. to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia Code DE (maximum number of places:1) (of the following gender: Female). Mental Disorder, excluding learning disability or dementia - Code MD (maximum number of places: 14). Date of last inspection Brief description of the care home Devon House is owned by Parkcare Homes Ltd. Devon House is a large, detached, modern house in a residential area of Oakwood. There are fourteen single bedrooms. All bedrooms have en-suite facilities and are located on two floors. The kitchen and dining room are at the front of the house. There is adequate communal space for the number of people who live in the home. There is a large garden to the rear of the property. The home aims to ensure people are supported to live as independently as possible. The organisations base fee is £780.00. The home has the Purpose and Care Homes for Adults (18-65 years) Page 4 of 31 Brief description of the care home Function Document and Inspection Report on their notice board for interested parties to view. Care Homes for Adults (18-65 years) Page 5 of 31 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 peterchart Concerns, complaints and protection Environment Staffing Conduct and management of the home Poor Adequate Good Excellent How we did our inspection: This was an unannounced inspection and took place as part of the inspection process. Compliance was checked against key standards and took a number of days as additional information was requested. We undertook a tour of the building spoke with the people who live in the home and members of the staff team. We gained further information from the Annual Quality Assessment Form, by an inspection of the documents kept in the home including care plans and health and safety documentation. The area manager manager, and deputy manager offered their assistance throughout the period of the inspection. I would like to thank the people that use the service, the management team and staff members for their openness and participation. Care Homes for Adults (18-65 years) Page 6 of 31 Care Homes for Adults (18-65 years) Page 7 of 31 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 Care Homes for Adults (18-65 years) Page 8 of 31 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.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 9 of 31 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 10 of 31 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 are provided with the information they need to make an informed choice about whether the service is suitable for them and their needs. No new people have moved into the home since the previous inspection. Therfore no new assessments had been undertaken. Evidence: Since the previous inspection there have been no new admissions to the home. There is an up to date statement of purpose, which ensures that the people living in the home are provided with clear information to enable them to decide if the home can meet their individual needs. The home also has an up to date service user guide, which also uses a pictorial format and is therefore accessible to all of the people who may wish to read the document. A copy of the service user guide is kept in each individual persons file and is available to them should they wish to refer back to the document. Care Homes for Adults (18-65 years) Page 11 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All care plans need to contain the most up to date information to ensure they can be used effectively to meet peoples individual needs. People do make decisions about their lives. Some identified risk assessments need to be updated. Currently identified risks are not fully minimised to ensure that all of the people living in the home are supported to take risks as part of an independent lifestyle. Evidence: The care plans were inspected. The care plans are person centred. Care plans are detailed. However the information in specific care plans needs to be updated as individual peoples specific needs have changed.This will ensure that the care plan accurately reflects peoples current circumstances and ensures their individual needs are met. Risk assessments are also being further updated. The staff are in the process of ensuring that all of the risk assessments are up to date. It was agreed that the risk Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: assessment for one identified person in relation to their personal care needs is updated as a priority. This person also has a policy in place to check that they are not smoking in their bedroom. This document had been completed but on the one occassion when the person was found to be smoking in their bedroom it did not evidence that any action had been taken by the staff member in relation to this. The document must evidence the action taken to further safeguard the health and wellbeing of the people living and working in the home. Risk assessments cover areas such as depression, self-neglect, verbal outbursts smoking, going out and finance. Care Homes for Adults (18-65 years) Page 13 of 31 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 are part of the community which enriches their lives. Activities are recorded effectively. People are assisted to maintain appropriate relationships. This promotes their emotional wellbeing. Peoples rights are respected. This makes them feel valued. The food available to people living in the home has improved. This benefits their dietary needs. However the tempreture at which food is being stored is not being effectively recorded. This does not fully safeguard the health and wellbeing of the people living in the home. Evidence: Applications had been made for people to attend college to enable them to expand their educational opportunities. However the people living at the home do not wish to take advantage of this opportunity. A number of people do attend various centres to partake in activities. Peoples activity records are now more accurately recorded to Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: evidence clear activities that had been undertaken for example, going shopping, lunch out, going to the snooker club, going to the pub, going to the fun day and disco night. One person attends a film group, yoga, and the leisure centre to take part in a swimming group. This assists people to be fully involved in their local community. People take part in the quiz night held at the home and board games. People living in the home like listen to their music and watch television. People also develop their own life skills by undertaking a number of domestic duties both independently and with assistance from staff. A number of people living at Devon House receive regular visits from their relatives and friends and go out togeather for lunch for example.This promotes their emotional wellbeing. People have keys to their bedrooms which some of the people in the home use to ensure their privacy is respected. Peoples spiritual needs are met as one person likes to listen to songs of praise and read their bible. Another person attends the church regularly and helps out there. The home does not have a vehicle of its own. All of the people living in the home have a freedom pass. This assists to further develop peoples independence. On the day of the inspection the kitchen was clean and tidy. The fridge and freezer were inspected and the food labelled appropriately. Food was being stored within their use by dates. This ensures that people are not eating food that is harmful to their health. However the fridge and freezer temperatures are not being effectively recorded.This does not promote the health and wellbeing of people living in the home. The menu of food available was seen and a more varied diet is now available to the people living in the home. Care Homes for Adults (18-65 years) Page 15 of 31 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 receive personal care in a way they prefer and require.This ensures their individual rights and choices are respected. Peoples physical and emotional health care needs are not being fully met as systems of recording are not effective. The process for recording and administering medication was found to be in order.However PRN guidelines need to be in place for this system to be fully effective. Evidence: Peoples health care appointments were inspected. They indicated that peoples health care appointments are not being effectively recorded. Information was not evidenced on the health appointment records to indicate when all appointments had been undertaken. It was requested by the area manager that the manager contact the relevant professionals on the day of the inspection to obtain a list of up to date appointments. A list was supplied.The list needs to be updated as it included individual people who arrange their own health care appointments at altenative dentists for example and they had not been removed from the current list provided. It was agreed that this information would be updated by the manager by contacting the relevant person. In some instances information had been noted on the daily recording sheet or Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: diary but not on the health record. This means that it is difficult to ensure that peoples health care needs are fully monitored. Peoples health action plans need to be fully up to date. Having had a discussion with the management team it appears that the format of the document is causing some confusion. It was noted on the day of the inspection that a detailed health report had been completed but the date the report was written was entered on the health action plan rather than the actual appointment date. The format of the document is going to be revised. It was agreed at the time of the inspection that all information needs to be updated and the information needs to be regularly reviewed. At the time of completing the report I have been informed that this task has been completed by the manager of the service. The records of peoples weight charts were up to date. This means that peoples weight monitoring programme is being effectively followed. This benefits peoples health and wellbeing. Peoples preferences in relation to how they wish their personal care to be provided is being highlighted in their individual care plans. This means the persons wishes are being respected. The medication and administration records were inspected and medication had been signed for on the medication administration records. In relation to guidelines being in place in relation to PRN medication one identified person did not have these guidelines available in the file on the day of the inspection. The manager printed a copy of the document off of the computer on the day of the inspection. The form needs to be signed and dated by the relevant professionals.This will ensure that all documents are available to those people that need to use them. The medication cupboard was inspected and found to be in order. There is an up to date list on file to indicate the staff that have undertaken training and can undertake the administration of medication. Care Homes for Adults (18-65 years) Page 17 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be confident that their views are listened to and acted upon since the recording and action taken in relation to complaints was found to be in order. People are protected from abuse neglect and self-harm as all of the required guidance was found to be in order with regard to adult protection policies and procedures. Evidence: The complaints book was inspected and there had been three complaints made since the previous inspection. The information had been recorded effectively and responded to appropriately and within appropriate timescales. The complaints procedure was up to date and is available in a pictorial easy read format. This ensures that it is fully accessible to all of the people that wish to read the document. People living in the home had been provided with a copy of the complaints procedure. This ensures that people know how to make a complaint if they need to. This further ensures that their individual rights are protected. The home had a copy of the adult protection guidance issued by the London Borough of Enfield which is the local authority the home is situated in. On the day of the inspection the manager also had available a copy of the organisations adult protection policy and procedure. This ensures that staff are provided with the necessary information to enable them to follow the professional procedures recorded in the Care Homes for Adults (18-65 years) Page 18 of 31 Evidence: document and act in a professional manner to protect the people living in the home from potential abuse. The whistle blowing policy was also seen and found to be in order. This ensures that people have the necessary information to report any concerns they may have in relation to practice that is being undertaken within the home. This assists to improve the quality of care provided to the people living in the home. Staff had undertaken adult protection training. However one member of staff needed to undertake refresher training and the manager was in the process of requesting this person attend the training. (Please refer to the staff training section of the report.) Staff have been provided with the necessary knowledge and skills to protect the people living in the home from potential abuse. The financial records of the people living in the home were inspected and were found to be in order. The home also has a safe to assist to safeguard the finances of the people living in the home. Care Homes for Adults (18-65 years) Page 19 of 31 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 are living in a clean safe environment, which benefits their wellbeing. Evidence: Devon House is a large detached modern house in a residential area in oakwood. There are fourteen single bedrooms. All bedrooms have en-suite facilities and are located on two floors. The kitchen and dining rooms are at the front of the house. There is a large garden to the rear of the property. On the day of the inspection Peoples bedrooms were inspected having sought their permission. The bedrooms were appropriately furnished. Bedrooms were personalised with peoples own individual items such as their pictures, music centres and a television. This assists people to maintain their identity and express their personality. On the day of the inspection the kitchen was clean and tidy. This protects the health and wellbeing of the people living and working in the home. The kitchen was appropriately equipped to enable staff to meet peoples needs when they are preparing meals with staff or cooking independently. During the inspection the following improvements were identified a new dish-washer Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: has been obtained in the kitchen. This ensures that the home is using equipment that is working effectively and promotes the health and safety of the people living in the home. A new kitchen bin had been obtained which ensures that waste products can be stored appropriately. The loft hatch is now in place and secure. This assists people to live in a safe environment. The bed in the staff sleep-in bedroom has been replaced. This ensures that staff are provided with a comfortable bed to sleep in at night. One identified person whos bedroom was showing signs of damp in an identified area has had the matter resolved and their bedroom has been painted. Another person who has their own ensuite and this was also showing signs of damp.The problem has been investigated, appropriate action has been taken and this bedroom has also been painted. A new table and chairs has been obtained for the dining area. This ensures they can sit and socialise togeather at meal times. On the day of the inspection the following areas that needed improvement were identified. One identified persons toilet was leaking and was repaired by the maintenance man.This toilet is now working effectively. One identified persons bedroom carpet was worn and needed to be replaced to ensure they had a pleasent bedroom to rest in. One identified person needed improved storage space in their bathroom to ensure their individual needs were met. One identified person that had a damp area starting to appear in a small area in their bedroom .The maintenance man on the day of the inspection identified a crack in the brickwork were the water was passing through this space and causing a problem. Two identified people needed their bedroom painted. To ensure they live in a comfortable environment. These were noted on the maintenance programme and the identified bedrooms have been decorated. The commission has been informed and provided with evidence that the above tasks have been completed during the time of completing the report.Therefore requirements have not been made. The area manager has also agreed to refurbish the shower room.This task has been included on the homes maintenance programme and work commences on the 14th of May 2009. Care Homes for Adults (18-65 years) Page 21 of 31 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. Not all of the staff had undertaken their refresher training in identified areas to ensure they can meet the needs of people living in the home. People living in the home are protected by the homes recruitment policies and procedures. Staff are receiving supervision which means that a consistant approach by staff can be maintained when working with the people living in the home. This improves the quality of care for the people living in the home. Evidence: The staff rota was inspected and there were adequate numbers of staff on shift to meet the needs of the people living in the home on the day of the inspection. Staff had undertaken a range of training this included fire safety training, protection of vulnerable adults training, food hygiene training, manual handling training, infection control training, equality and diversity training, health and safety training, non-violent crisis intervention training, fire marshall training, appointed first aider training and medication training. A number of staff had also undertaken the national vocational qualification level 2, 3 and one staff member had started level 4. However some individual staff members need to undertake refresher training in relation to fire safety training, non-violent crisis intervention training, health safety and cosHH training, Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: medication training, and one person needs to update their protection of vulnerable adults training. It has also been advised that staff undertake epilepsy training. This will ensure that staff have the necessary skills and knowledge to meet the needs of the people living in the home. Staff files were inspected and contained all of the criminal records bureau checks, staff references and required staff identification records which assist to protect people living in the home from potential abuse. The staff supervision records were inspected and staff are receiving regular supervision. A new supervision format is in place which improves the supervision process. A discussion took place with the manager and area manager in relation to the supervision document and it was agreed that the manager will ensure that the information recorded on this new recorded is is consistently detailed on all of the supervision records. The supervision process has improved.This ensures that staff have the opportunity for personal development.This will also improve the quality of care provided to the people living in the home. Care Homes for Adults (18-65 years) Page 23 of 31 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 quality assurance system took into account the views of people living in the home. This assists with their self -monitoring and development of the home. Peoples health safety and welfare will only be fully protected when an effective notification system is implemented by the home. Evidence: The organisation has an established quality assurance system in place. This assists to improve the quality of care for people living in the home. The Care Quality Commission has not been sent regulation 37 notifications of incident forms in relation to two specific incidents identified on the day of the inspection. These incidents had been responded to by the organisation and their own records had been completed. However the information had not been forwarded to the commission.This means that professional practice in relation to this specific area is not being followed and was discussed with the area manager and manager on the day of the inspection. A range of health and safety documentation was seen and indicated that the gas Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: certificate, electrical installation certificate, records of emergency lighting tests, servicing of the fire alarm, fire fighting equipment, fire risk assessment, fire evacuation plan and current public liability insurance were found to be in order.This indicates that peoples health and safety is being taken seriously by the home in relation to these identified areas. Care Homes for Adults (18-65 years) Page 25 of 31 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 31 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 6 15 The Registered Person must ensure that all the specific areas of the care plan contain the most up to date information. This will ensure the care plan reflects the persons changing needs. This will ensure their changing needs can be met. 17/06/2009 2 9 15 The Registered Person must 20/05/2009 ensure that when people are found smoking in their bedroom that the action taken in relation to this is noted on the smoking record. This will ensure that clear recording is available to indicate the action taken to safeguard the health and wellbeing of people living and working in the home. 3 9 15 The Registered Person must ensure that all risk assessments are up to date. 22/05/2009 Care Homes for Adults (18-65 years) Page 27 of 31 This will ensure that all identified risks are minimised. This will safeguard the health and wellbeing of the people living and working in the home. 4 17 16 The Registered Person must ensure that the fridge and fridge freezer temperatures are effectively recorded. This will ensure that the health and wellbeing of the people living in the home is promoted and protected. 5 19 12 The Registered Person must 22/05/2009 ensure that the health action plan format is improved and that this information is kept up to date and effectively recorded. This will ensure that action taken to monitor peoples health care needs can be effectively monitored. 6 19 12 The Registered Person must ensure that when health care appointments are undertaken they are effectively recorded on the correct documentation with outcomes. This will ensure that effective recording is in place to fully evidence that peoples health care needs are met. 22/05/2009 23/05/2009 Care Homes for Adults (18-65 years) Page 28 of 31 7 20 12 The Registered Person must ensure that PRN guidelines are in place and available in the medication folder for inspection. This will ensure that clear and accurate procedures are in place for staff. The will ensure that professional practice is followed. 20/05/2009 8 35 23 The Registered Person must ensure that staff undertake refresher training in fire safety training, non-violent crisis intervention training, health safety and CosHH training, adult ptotection training, medication and epilepsy training. This will ensure that the staff have the necessary knowledge and skills to meet the needs of the people living in the home. 12/07/2009 9 37 37 The Registered Person must ensure that the Care Quality Commission is informed of all notifications of incidents that advsrsley affect the wellbeing of people living in the home. This will ensure that legal requirements are met and that professional practice is followed. 22/05/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of Care Homes for Adults (18-65 years) Page 29 of 31 improving their service. No. Refer to Standard Good Practice Recommendations 1 36 The supervision documentation needs to be consistently detailed on all of the supervision records to indicate goals and action taken by the identified person. Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) 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. 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