Inspection on 09/02/09 for Dunsland Residential Home

This inspection was carried out on 9th February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Dunsland Residential Home 23 Paston Road Mundesley Norwich Norfolk NR11 8BN The quality rating for this care home is: One Star Adequate 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: Ruth Hannent Date: 0 9 0 2 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. They reflect the things that people have said are important to them: 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. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 33 Care Homes for Adults (18-65 years) Audience Further copies from Copyright 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.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: Dunsland Residential Home 23 Paston Road Mundesley Norwich Norfolk NR11 8BN 01263720618 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Cephas Care Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 14 Number of places (if applicable): Under 65 Over 65 14 0 learning disability Additional conditions: The registered person may provide the following categories 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: Learning Disability - Code LD The maximum number of service users who can be accommodated is 14 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 33 A bit about the care home This is an older style property that was originally two houses but has now been knocked into one. It stands yards from the sea front in Mundesley and has a small parking area at the front of the property and a small garden to the back with a large summer house. The home is registered for 14 people who need to be able to climb stairs as there is no lift to move from floor to floor. The bedrooms are for single occupancy with some having en-suite facilities. There is a large lounge, large dining room and large kitchen. Residents have access to facilities in the village and also in the towns of Cromer, Sherringham and Holt. Care Homes for Adults (18-65 years) Page 5 of 33 The home charges 700 pounds per week as a standard charge but may charge more according to need. Care Homes for Adults (18-65 years) Page 6 of 33 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 Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 7 of 33 How we did our inspection: This is what the inspector did when they were at the care home This inspection visit took place after six months of the new owners taking over the service. As this is a new service for a Company that is established in other parts of the country the policies and procedures set are the same. The Annual Quality Assurance Assessment had been completed and return by the Manager who has been in most for three months. This document was used to complete this inspection. Since the Company took over the Commission has not received any notifications, complaints or concerns. Care Homes for Adults (18-65 years) Page 8 of 33 Three surveys completed by staff and a health professional has been taken into account. Three staff and three residents were spoken to on the day of this visit. The visit and tour of the premises was carried out with the Manager and then joined by one of the Company Directors. What the care home does well There is a homely feel to the service with rooms and communal areas comfortable and clean. The staff have been at the home for a number of years and know the residents well to be able to offer a person centred care approach. Care Homes for Adults (18-65 years) Page 9 of 33 The relationship with the GP is positive with good feedback received on the interactions between the home and the medical staff who attend the residents. The individual bedrooms are personalised and furnished with suitable items that allows residents to have the room laid out as they wish. What has got better from the last inspection What the care home could do better The home needs to employ staff at times throughout the week that ensure the needs of residents are met, especially at the weekends. Page 10 of 33 Care Homes for Adults (18-65 years) The staff need to complete records fully to ensure that good health and safety practise is taking place. The way the money that is allocated for purchasing food is actually spent needs to be reviewed, and not used for buying fuel for the homes vehicle to ensure there is enough money to buy the food required. Potential residents to the home need to be fully assessed prior to admission, regardless of if it is an emergency admission or a planned stay. Care Homes for Adults (18-65 years) Page 11 of 33 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Ruth Hannent Cambridge LO CPC1 Capital Business Park Fulbourn Cambridge CB21 5XE 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 12 of 33 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 13 of 33 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home does have information about the Home that can be given to potential customers. The Home does have a clear procedure for assessing potential residents but this has not been implemented with an emergency placement and should have been. Evidence: The company had sent to the Commission the Statement of Purpose when they took over this home. We looked at this information prior to this inspection and all relevant details are available but could be improved if available in picture format. Using pictures was discussed with the new Manager and this is something planned for the future. This home has only been owned by this company since August 2008. The people who live in Dunsland House have been living there for quite a while and the assessment process is different with the new company to the way people who live there have been assessed before. The home is registered for 14 and on the day of this inspection had 12 permanent residents with another person taken in as a temporary resident in November. This arrangement was for 1 weeks emergency respite and has been Care Homes for Adults (18-65 years) Page 14 of 33 Evidence: extended on a regular basis while helping this person find suitable accommodation. This person was admitted with very limited information and any details obtained were written on a note pad. Nothing in detail has been sent from Social Services and the temporary arrangement is still happening. This person is not appropriate for this home and needs to move on. Both the Social Workers and Home Management are trying to find suitable placements, but this is taking longer than expected and with very limited information in the home about this person this should not continue. We spoke to this person in some length and found the anxiety levels were raised and according to staff this causes concerns for the other residents. It is evident that comprehensive details for any type of placement needs to be available to help the home assess if the needs can be met or not. Extending the placement for someone who is not suitable is not for the best of the other residents. The new company does have a clear procedure when assessing new potential clients and these were discussed in full. Future potential clients will have a thorough assessment before being offered a place in the home. The Manager who completed the Annual Quality Assurance Assessment gave a full picture of how the assessment procedure should be carried out and on verbally discussing this it will be the case in the future. Care Homes for Adults (18-65 years) Page 15 of 33 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 . The home will have new version care plans in place shortly. Residents can make decisions about their lives. Residents do take risks as part of their independent life style but some risk assessment records are not yet up to date.. Evidence: The new Manager has been in post since November 2008 and has started to improve the care plan documentation within the home. The existing ones are available but very full of paperwork that needs to be filed away. The new care plan formats were seen and one completed version was looked at in detail. It was written in a language that was suitable for this clientelle and did have some picture format. The wording was all around the person making them individual and personalised. This person was spoken to briefly during this visit and the care plan information was appropriate. The need to get everyones care plans up to date is necessary as the old formats are no longer relevant. Care Homes for Adults (18-65 years) Page 16 of 33 Evidence: Observing staff during this visit it was apparent how supportive they are of each resident. On this day three residents were at home with all the others out at various placements. Choices of what they would like for lunch was available. Their rooms were all very much their own rooms with choices of how to personalise them seen. The new version care plans show how risks are assessed and how management strategies are in place to allow residents to live the lifestyle they like. The AQAA also tells us of how the risks are assessed and managed to allow choices and that these assessments will be regularly reviewed. Some staff spoken to said that some individual risk assessments still need to be recorded as residents become more independent in the home. Care Homes for Adults (18-65 years) Page 17 of 33 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents do take part in appropriate activities. Residents are involved in local activities but the home is to work hard at encouraging more involvement with families and friends. The home has increased the independence that people have in their daily routines. Evidence: On the day of this inspection the majority of the residents were out at various centres in Holt and Sherringham. Others were attending a cluster group with friends. The local community of Mundesley are involved and include Dunsland House in village life. The residents often visit the local pub and walk the village and the beaches in the better weather. Care Homes for Adults (18-65 years) Page 18 of 33 Evidence: According to the staff leisure interests have not been taking place as often as would be enjoyed as there has not been enough staff at the weekends to take people out. The residents have not had a holiday for a long time and plans at residents meetings have begun to think about holidays as requested by the residents. Minutes seen. The Manager gave examples of where the residents have said they would like to spend a holiday such as a local seaside resort to holidays abroad. The only visitors who arrived on the day of this inspection was 2 representatives from Social Services. They were introduced to us and welcomed in the building. The residents have not had much contact with families and friends in the past but the Manager is planning to encourage people to visit more often and aims to have events to invite people to. The AQAA tells us that residents are offered choice and the plans for the future is to have a display board with appropriate pictures as well as notices on what activities are available. Staff comments received tell us that residents are being encouraged to be more independent since the new company took over which I find really positive is just one comment. The menu for the week was on display in the kitchen and showed the choice offered to residents. There was some choice seen but the week of this inspection showed quite a lot of sausage such as toad in the hole or sausages which was not really a choice for the Monday and then sausages again on the Thursday. One person spoken to said she could have basically what ever she wanted if it was in the cupboard. Some of the staff commented that the amount of money available for buying the food was not always enough and value labels of produce was being bought and were not of suitable quality. The residents also like to purchase a bag of chips from the local chip shop but have to buy these out of their own money. On discussing the money available for food with management it appears that 20 pounds is allowed per resident per week. This amount would be suitable for food only but staff were concerned that fuel for the vehicle has to come out of this money and that some non food items such as toilet rolls and washing up liquids were also having to be purchased. The lunch was observed with one person having beans on toast and another having a sandwich. They said they enjoy their meals and especially the take away at the weekends. The management told us of the way people now prepare and get their own breakfasts as and when they require. Previous practise would have seen everything set out with juice poured out and milk on the cereal before the person was ready to have their breakfast. Care Homes for Adults (18-65 years) Page 19 of 33 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 . Residents are supported, when appropriate, with their personal care in a way that they prefer through the week but less at weekends. The health care needs of resident are met. Medication procedures are followed but some good practises could be in place to improve further the methods used. Evidence: The residents who live at Dunsland are fairly independent with their personal care. According to staff, some need encouragement to ensure they are timely with their own hygiene. Three residents seen appeared to be dressed and in clothes chosen by themselves. Each resident has a designated key worker and one lady spoken to knew who her special worker was. The staff did report that people are not so well supported at the weekends as all residents are home and needing more support when there are less staff on duty. The residents are supported for their health care needs and are transported to appointments when required. One GP had returned a comment survey that gave the Care Homes for Adults (18-65 years) Page 20 of 33 Evidence: home positive comments such as there is good communication with the medical team, medication changes are taken immediately and the team participate very actively with clinicians. The medication cupboard is an understairs locked room that holds the locked trolley that is secure. The medicines are prepared by Boots and stored appropriately. The home has just had delivered a separate fridge that will store medication that requires fridge temperatures but this is still to be unpacked. The medication record sheets (MAR) are completed and signed for on administration but noted was the large amount of medication for each individual for as required. The home to date does not have a homely remedy policy and each resident has an amount of homely remedies that were in fact not used. Some PRN that is required had some signatures dotted in some dates. Good practise would be to place an N in the initial box to show the person has been looked at and a decision between the resident and the staff has been made not to administer at this time. The staff have received medication training and the Manager did inform us that no one would administer medication who was not trained and competent. Care Homes for Adults (18-65 years) Page 21 of 33 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 . The home does have a complaints procedure and residents will be listened to. Residents are protected from abuse. Evidence: The home does have a complaints procedure but this was not evident and on display and in a format that could be understood by the residents. the Manager has started to have regular meetings with residents and minutes were available and read. There does not seem to be any complaints since this company took over and the Commission has not received any. The Manager has completed the AQAA comprehensively, giving examples of how and in what timescale to deal with a complaint if one arises. The Commission has not received any notifications to say any safeguarding issues have arisen. The staff are aware on talking to us of their responsibility to report on any concerns and the policy for whistle blowing is available. The AQAA also tells us that all staff members go through an enhanced CRB check and POVA first before they are employed. Care Homes for Adults (18-65 years) Page 22 of 33 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 building is homely, comfortable and safe. The bedrooms are personalised and promote independence and suit the lifestyles of the individual. Shared space will be improved when the extra lounge is available. Evidence: The home has in the past been two separate houses and is now connected making a large home with lots of character. Although the home has only been with this company 6 months many areas have already started to show improvement. The electric supply for some parts of the home were found to be in a dangerous condition and this has now been rectified with many rooms and corridors now having brighter lit areas. All the areas seen were clean and tidy. The individual bedrooms (three seen) were very much personalised with one decorated and furnished with Norwich City colours, another was very much a soft warm room with classic dolls on display and nice bed covers. The one main lounge has now had more appropriate living room furniture installed and another area that is at present part of an office will shortly become another lounge. The home does have some steep stairs and would not be a suitable environment to Care Homes for Adults (18-65 years) Page 23 of 33 Evidence: care for people with mobility problems. One resident who is now finding the stairs difficult has been given a room on the ground floor. One bedroom was found to have a carpet that had been cut and the threads were a trip hazard. This was to be trimmed immediately and the carpet made safe. Some of the rooms had their own showers/en suites and some were shared between 2. All these rooms were clean and tidy and no unpleasant odours were detected. The home has a washing machine and tumble dryer in a separate room with limited space meaning airing and ironing of clothes was done in the dining/kitchen area. The fire officer had visited the home the week prior to this inspection and a fire safety certificate was seen. The full report of this latest inspection had not arrived at the home to date but the Manager informed us that there had been no concerns. The garden has been cleared and is to be improved to ensure people will be able to access all of the areas. A summer house is to be cleared of old furniture and made into a games room within the next year. Care Homes for Adults (18-65 years) Page 24 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Residents do understand the roles of the staff and do benefit. The staff are competent and qualified to carry out their roles with those not qualified being supported to gain the qualification. The staff are not deployed in an effective way to meet fully the needs of the residents. The procedures for recruiting new staff members is robust and protects the residents. Staff are appropriately trained to meet the residents needs. Supervision of staff is now in place and will benefit the residents. Evidence: The staff at this home are called support workers and do all tasks required to ensure the home is running effectively. They care, clean, shop and cook as part of their work role. It is not so clear how much one to one support the staff have time for, especially when all the residents are at home. Care Homes for Adults (18-65 years) Page 25 of 33 Evidence: The majority of the staff have already achieved their NVQ 2 award and some are aiming towards NVQ 3. Noted on the office wall was the planned day for those who are yet to qualify and will be having an introductory day on the 25th March. The staff team on duty plus one comment survey from a staff member and one from the GP all mention the need for more staff especially at weekends when the residents are all at home and there is only two or sometimes three staff on duty. The staff spoken to feel the need to carry out domestic chores and cook means less time is spent with the residents. The GP states they do well but may benefit by having additional staff. The staff do say that regular meetings are taking place but that they are not always listened to. The management are aware of the difficulties during this transition of working with new employers and say they are trying to work with the staff team to get the balance of work right with the correct amount of staff on duty to meet the needs. On the day of this inspection three staff were on duty and only three residents were at home. The rotas are being looked at in depth and staff have been asked to try and work the rotas to ensure enough staff are on duty at relevant times. The home staff team have all been employed, except for one new staff, prior to the new company taking over. The one persons personnel file was looked at and relevant documentation was seen to show that safe recruitment procedures had been carried out. Two forms of identification, CRB and POVA first, two references were all in place. The company have a number of staff who have become experts in certain fields of care and go from home to home offering training sessions to the staff. The staff spoken to (3) all felt the training offered is good and that there is plenty of training. Certificates were seen in the personnel files but some appeared quite old and needed renewing. The home does not have a training matrix to date which would be a useful tool to plan and deliver training in a timely manner. The three staff spoken to all said that supervision sessions on a regular basis had begun and that they were pleased with the way the Manager is trying to work with them. The Manager is still getting to know the staff and is beginning to build a relationship with them. Care Homes for Adults (18-65 years) Page 26 of 33 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 will benefit from a well run home once the Manager has established the new ways of working. The home has not yet completed a quality assurance system. The health, safety and welfare of residents and staff is protected and promoted. Evidence: The Manager of the home has been in post three months and has already implemented some positive changes. She has on display in the office her certificates of management qualifications including an RMA and Management Diploma Level 5. On talking to her during this inspection it was clear that this person has a lot of knowledge and experience. Systems of good management have already started such as planned residents and staff meetings, one to one supervision, staff training and home development plans. The application for becoming the registered Manager has been submitted to CSCI but a CRB has yet to be completed so the process can not go ahead until this is done. Care Homes for Adults (18-65 years) Page 27 of 33 Evidence: The company does have a system to carry out quality monitoring procedures but as yet the home has not undertaken this during this initial settling period. The policies and procedures are held in a file that are generic for all the homes in this company. Staff are finding it difficult coming to terms with different procedures but are aware that there are procedures in place. To ensure safe practises are taking place the home has recording systems that were seen such as food handling, fridge temperatures, water temperatures, cleaning schedules etc. These records were not being completed and many of the dates were missing. There was no consistency in the records and some of the forms repeated themselves. The home has recently completed a fire training session, COSHH sessions were noted on the wipe board in the office and the AQAA tells us that the safety data sheets for COSHH are in place. The Manager had also found that fire records such as alarm testing had not been carried out weekly. The records seen now show a clear start date that tests are now carried out weekly. The Manager has also obtained the Safer Food, Better Business guide (seen) and has a day planned for training with the Environmental Health Officer. Care Homes for Adults (18-65 years) Page 28 of 33 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 33 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 Description 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 Description Timescale for action 1 2 14 The Home shall not provide accommodation to any resident who has not been fully assessed by a qualified person and a copy is available. 01/03/2009 To ensure any person admitted can have their needs met appropriately. 2 6 15 The home needs to ensure the new version care plans are in place and up to date 01/04/2009 To ensure that staff have a guide that is detailed and includes the risk assessments. 3 33 18 The Manager must ensure that staff are deployed in suitable numbers at times that suit the needs of the residents 01/03/2009 Care Homes for Adults (18-65 years) Page 30 of 33 To ensure that, especially at weekends, enough staff are on duty to meet all the needs of the residents. 4 42 13 The Manager must ensure 01/04/2009 that recordings for health and safety within the home are accurate and up to date. To ensure that residents and staff are protected by good procedures in place that record all areas of health and safety such as food, fire and cleaning. 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 1 17 It is recommended that any information about the home is also offered in picture format. It is recommended that the budget set for purchasing food is spent on what it is planned for and that staff understand what the procedures are for purchasing other items such as fuel. It is recommended that the menus are looked at more in depth to ensure choices are more varied and not have the same or similar meat as the choice. It is recommended that the home has a homely remendies procedure and that PRN medication is recorded when and when not given to show the person has been observed/spoken to as to if the medication is or is not required. It is recommended that on display is a complaints procedure that is easy to understand and could contain pictures that are suitable for the client group cared for. It is recommended that a training matrix is in place to ensure the training is given, reviewed and renewed when 3 17 4 20 5 22 6 35 Care Homes for Adults (18-65 years) Page 31 of 33 required. 7 37 The manager should register with the Commission as soon as possible. Care Homes for Adults (18-65 years) Page 32 of 33 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 © (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. Care Homes for Adults (18-65 years) Page 33 of 33 - 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!